1.

Hazard and Risk Analysis

2. Hazard and Risk Analysis quantitative and qualitative:

qualitative and perform quantitative risk analysis are two processes within the project risk
management knowledge area, in the planning process group. Understanding the difference
between the two processes
While qualitative risk analysis should generally be performed on all risks, for all projects,
quantitative risk analysis has a more limited use, based on the type of project, the project risks,
and the availability of data to use to conduct the quantitative analysis.
i) Qualitative Risk Analysis
A qualitative risk analysis prioritizes the identified project risks using a pre-defined rating scale.
Risks will be scored based on their probability or likelihood of occurring and the impact on
project objectives should they occur.
Probability/likelihood is commonly ranked on a zero to one scale (for example, .3 equating to a
30% probability of the risk event occurring).
The impact scale is organizationally defined (for example, a one to five scale, with five being the
highest impact on project objectives - such as budget, schedule, or quality).

A qualitative risk analysis will also include the appropriate categorization of the risks, either
source-based or effect-based.
ii) Quantitative Risk Analysis
A quantitative risk analysis is a further analysis of the highest priority risks during a which a
numerical or quantitative rating is assigned in order to develop a probabilistic analysis of the
project.
A quantitative analysis:

Quantifies the possible outcomes for the project and assesses the probability of
achieving specific project objectives
Provides a quantitative approach to making decisions when there is uncertainty
Creates realistic and achievable cost, schedule or scope targets

In order to conduct a quantitative risk analysis, you will need high-quality data, a well-developed
project model, and a prioritized lists of project risks (usually from performing a qualitative risk
analysis)
3.Failure,Mode and Effect Analysis (FMEA)
Also called: potential failure modes and effects analysis; failure modes, effects and criticality
analysis (FMECA).
Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible
failures in a design, a manufacturing or assembly process, or a product or service.
Failure modes means the ways, or modes, in which something might fail. Failures are any
errors or defects, especially ones that affect the customer, and can be potential or actual.
Effects analysis refers to studying the consequences of those failures.
Failures are prioritized according to how serious their consequences are, how frequently they
occur and how easily they can be detected. The purpose of the FMEA is to take actions to
eliminate or reduce failures, starting with the highest-priority ones.
Failure modes and effects analysis also documents current knowledge and actions about the risks
of failures, for use in continuous improvement. FMEA is used during design to prevent failures.
Later its used for control, before and during ongoing operation of the process. Ideally, FMEA
begins during the earliest conceptual stages of design and continues throughout the life of the
product or service.
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When to Use FMEA

When a process, product or service is being designed or redesigned, after quality

function deployment.
When an existing process, product or service is being applied in a new way.
Before developing control plans for a new or modified process.
When improvement goals are planned for an existing process, product or service.
When analyzing failures of an existing process, product or service.
Periodically throughout the life of the process, product or service

4.Maximum credible accident analysis(MCAA)

A Maximum Credible Accident (MCA) can be characterized, as an accident with a maximum
damage potential, which is still believed to be probable. MCA analysis does not include
quantification of the probability of occurrence of an accident. Moreover, since it is not possible
to indicate exactly a level of probability that is still believed to be credible, the selection of MCA
is somewhat arbitrary. In practice, the selection of accident scenarios representative for a MCAAnalysis is done on the basis of engineering judgement and expertise in the field of risk analysis
studies, especially accident analysis. Major hazards posed by flammable storage can be identified
taking recourse to MCA analysis. MCA analysis encompasses certain techniques to identify the
hazards and calculate the consequent effects in terms of damage distances of heat radiation, toxic
releases, vapour cloud explosion etc. A host of probable or potential accidents of the major units
in the complex arising due to use, storage and handling of the hazardous materials are examined
to establish their credibility. Depending upon the effective hazardous attributes and their impact
on the event, the maximum effect on the surrounding environment and the respective damage
caused can be assessed. As an initial step in this study, a selection has been made of the
processing and storage units and activities, which are believed to represent the highest level or
risk for the surroundings in terms of damage distances. For this selection the following factors
have been taken into account:

Type of compound viz. flammable or toxic;

Quantity of material present in a unit or involved in an activity; and
Process or storage conditions such as temperature, pressure, flow, mixing and
presence of incompatible materials.

In addition to be above factors, the location of a unit or activity with respect to adjacent
activities is taken into consideration to account for the potential escalation of an accident. This
phenomenon is known as the Domino Effect. The units and activities, which have been selected
on the basis of the above factors, are summarized; accident scenarios are established in hazard
identification studies, while effect and damage calculations are carried out in Maximum Credible
Accident Analysis Studies.

Methodology:
Following steps is employed for visualization of MCA scenarios:

Chemical inventory analysis;

Identification of chemical release and accident scenarios;
Analysis of past accidents of similar nature to establish credibility to identified
scenarios; and
Short-listing of MCA scenarios.

4.Fault tree analysis

is a top down, deductive failure analysis in which an undesired state of a system is analyzed
using Boolean logic to combine a series of lower-level events. This analysis method is mainly
used in the fields of safety engineering and reliability engineering to understand how systems can
fail, to identify the best ways to reduce risk or to determine (or get a feeling for) event rates of a
safety accident or a particular system level (functional) failure.
FTA is used in the aerospace, nuclear power, chemical and process,[1][2][3] pharmaceutical,
[4]
petrochemical and other high-hazard industries; but is also used in fields as diverse as risk
factor identification relating to social service system failure.[5] FTA is also used in software
engineering for debugging purposes and is closely related to cause-elimination technique used to
detect bugs.
In aerospace, the more general term "system Failure Condition" is used for the "undesired state" /
Top event of the fault tree. These conditions are classified by the severity of their effects. The
most severe conditions require the most extensive fault tree analysis. These "system Failure
Conditions" and their classification are often previously determined in the functional Hazard
analysis

.
Fault Tree Analysis can be used to:

understand the logic leading to the top event / undesired state.

show compliance with the (input) system safety / reliability requirements.

prioritize the contributors leading to the top event - Creating the Critical
Equipment/Parts/Events lists for different importance measures.

monitor and control the safety performance of the complex system (e.g., is a particular
aircraft safe to fly when fuel valve x malfunctions? For how long is it allowed to fly with
the valve malfunction?).

minimize and optimize resources.

assist in designing a system. The FTA can be used as a design tool that helps to create
(output / lower level) requirements.

function as a diagnostic tool to identify and correct causes of the top event. It can help
with the creation of diagnostic manuals / processes.

5.Event tree analysis

Event tree analysis (ETA) is a forward, bottom up, logical modeling technique for both success
and failure that explores responses through a single initiating event and lays a path for assessing
probabilities of the outcomes and overall system analysis. This analysis technique is used to
analyze the effects of functioning or failed systems given that an event has occurred. ETA is a
powerful tool that will identify all consequences of a system that have a probability of occurring
after an initiating event that can be applied to a wide range of systems including: nuclear power
plants, spacecraft, and chemical plants. This Technique may be applied to a system early in the
design process to identify potential issues that may arise rather than correcting the issues after
they occur. With this forward logic process use of ETA as a tool in risk assessment can help to
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prevent negative outcomes from occurring by providing a risk assessor with the probability of
occurrence. ETA uses a type of modeling technique called event tree, which branches events
from one single event using Boolean logic.
Steps to perform an event tree analysis:
1. Define the system: Define what needs to be involved or where to draw the boundaries.
2. Identify the accident scenarios: Perform a system assessment to find hazards or
accident scenarios within the system design.
3. Identify the initiating events: Use a hazard analysis to define initiating events.
4. Identify intermediate events: Identify countermeasures associated with the specific
scenario.
5. Build the event tree diagram
6. Obtain event failure probabilities: If the failure probability can not be obtained
use fault tree analysis to calculate it.
7. Identify the outcome risk: Calculate the overall probability of the event paths and
determine the risk.
8. Evaluate the outcome risk: Evaluate the risk of each path and determine its
acceptability.
9. Recommend corrective action: If the outcome risk of a path is not acceptable develop
design changes that change the risk.
10.Document the ETA: Document the entire process on the event tree diagrams and update
for new information as needed.
6) Hazard, Hazid, Hazan and Hazop part of Safety and Risk Management

1) Hazard, Hazid (hazard identification), Hazan (hazard analysis), and Hazop (hazard
and operability studies) are important safety and risk management techniques in the
industry.
For the characterization of hazards, the following are the key indicators in terms of the
situation.

Magnitude and intensity ranges

Time and season
Duration
Timeline of development
Place and extent of impact area
Frequency
Possibility of its prediction
Related hazards
Cascading effects

(i)Hazard identification or Hazid

Hazid stand for hazard Identification. Steel industry, which is a high risk industry, often requires
that all hazards with the potential to cause a major accident are identified.
Hazid is a high level hazard identification technique which is commonly applied on an area by
area basis to hazardous installations. Hazid study is the systematic method of identifying hazards
to prevent and reduce any adverse impact that could cause injury to personnel, damage or loss of
property, environment and production, or become a liability. It is a component of the risk
assessment and risk management. It is being used to determine the adverse effects of exposure to
hazards and to plan necessary actions to mitigate such risks.

Hazid is one of the best known methodologies to identify potential hazards because it provides a
structured approach to identify hazards, potential undesirable consequences, and evaluate the
severity and likelihood of what is identified. Hazid involves machine or equipment designers,
management and end users, and ensures a full identification of hazards and safeguard procedures
in a workplace.
There are the following two possible purposes in identifying hazards.

To obtain a list of hazards for subsequent evaluation using other risk assessment
techniques. This is sometimes known as failure case selection.
To perform a qualitative evaluation of the significance of the hazards and the
measures for reducing the risks from them. This is sometimes known as hazard
assessment.

Through Hazid, management identifies, in consultation with employees, contractors (as far as is
practicable) and safety personnel the following.

All reasonably foreseeable hazards at the plant that may cause a major accident
The kinds of major accidents that may occur at the plant, the likelihood of a major
accident occurring and the likely consequences of a major accident.

Hazid process is to be an ongoing to ensure existing hazards are known, and new hazards are
recognized before they are introduced due to the following.

Prior to modification of any facility

Prior to change in the method of work or workforce
Before and during abnormal operations, troubleshooting
Plant condition monitoring, early warning signals, employee feedback from routine
participation in work, and after an incident.

Hazid is a transparent process and is critical to the safety of the plant, equipment, and operating
personnel. The benefits of Hazid studies include the following.

It is a flexible method which is applicable to any type of installation

It reveals hazards at an early stage before they happen
It leverages the experience of operating personnel as part of the team
It identifies hazards, cause and consequences as well as preventive measures
Hazards are recorded and managed to be avoided, mitigated or highlighted
It establishes screening criteria for hazards
Non critical hazards are documented to demonstrate that the events in question could
be safely ignored

(ii)Hazard analysis or Hazan

Hazan is a hazard analysis and is a term used in safety engineering for the logical, systematic
examination of an item, process, condition, facility, or system to identify and analyze the source,
causes, and consequences of potential or real unexpected events which can occur. A hazard
analysis considers system state (e.g. operating environment) as well as failures or malfunctions.
Hazan is the identification of undesired events that lead to the materialization of a hazard, the
analysis of the mechanisms by which these undesired events could occur, and, usually, the
estimation of the consequences. Every hazard analysis consists of the following three steps.

Estimating how often the incident will occur.

Estimating the consequences for the employees, the process, the plant, the public and
the environments.
Comparing the results of first two steps with a target or criterion to decide whether or
not action to reduce the probability of occurrence or to minimize the consequences is
desirable, or whether the hazard can be ignored, at least for the time being.

Hazan is therefore the essential prerequisite for the complete risk assessment process which
includes (i) analysis of the hazards, (ii) assessment of the risks which the hazards present, and
(iii) determination of ameliorating measures, if any, required to be taken.
Hazan is the first step in the process used for the assessment of the risk. The result of a hazard
analysis is the identification of different type of hazards. A hazard is a potential condition which
either exists or not exists (probability is 1 or 0). It may in single existence or in combination with
other hazards (sometimes called events) and conditions become an actual functional failure or
accident (mishap). The way this exactly happens in one particular sequence is called a scenario.
This scenario has a probability (between 1 and 0) of occurrence. Often a system has many
potential failure scenarios. It also is assigned a classification, based on the worst case severity of
the end condition. Risk is the combination of probability and severity. Preliminary risk levels can
be provided in the hazard analysis. The main goal of hazan is to provide the best selection of
means of controlling or eliminating the risk.
(iii)Hazard and operability study or Hazop
A hazard and operability (Hazop) study is a design review technique used for hazard
identification, and for the identification of design deficiencies which may give rise to operability
problems. It is a structured and systematic examination of a planned or existing process or
operation in order to identify and evaluate problems that may represent risks to personnel or
equipment, or prevent efficient operation. Hazop is most commonly applied to systems which
transfer or process hazardous substances, or activities where the operations involved can be
hazardous and the consequences of failure to control hazards may be significant in terms of
damage to life, the environment or property. A hazop study is carried out using a structured
approach by an experienced multi-discipline team, facilitated by a hazop leader. The hazop
technique is qualitative, and aims to stimulate the imagination of participants to identify potential
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hazards and operability problems. The relevant international standard calls for team members to
display intuition and good judgment and for the meetings to be held in a climate of positive
thinking and frank discussion. The hazop technique was initially developed to analyze chemical
process systems and mining operation process but has later been extended to other types of
systems and also to complex operations such as steel plant operation and to use software to
record the deviation and consequence.
Hazop is a structured and systematic technique for system examination and risk management. In
particular, Hazop is often used as a technique for identifying potential hazards in a system and
identifying operability problems likely to lead to nonconforming products. Hazop is based on a
theory that assumes risk events are caused by deviations from design or operating intentions.
Identification of such deviations is facilitated by using sets of guide words as a systematic list
of deviation perspectives. This approach is a unique feature of the Hazop methodology that helps
stimulate the imagination of team members when exploring potential deviations.
As a risk assessment tool, Hazop is often described as the following.

A brainstorming technique.
A qualitative risk assessment tool.
An inductive risk assessment tool, meaning that it is a bottom-up risk identification
approach, where success relies on the ability of subject matter experts to predict
deviations based on past experiences and general subject matter expertise

(iv) Management oversight review technique (MORT)

has provided a technique for thorough, searching investigation of occupational accidents ard
analysis of safety programs. MORT has been used to improve safety in specific activities and in
organizations. The announced goal is an order of magnitude reduction in already low accident
rates or probabilities. MORT is a formal, disciplined logic or decision tree to systematically
relate and integrate a wide variety of safety concepts: Sequential roles of energy, barriers to
energy transfer, error, change and risk.
A new, functional definition of an accident. Present best safety practices, system safety
technology, and behavioral, organizational and analytic sciences.
Methods of enhancing safety form a dynamic safety system congrous with general systems for
management of high performance . Safety program features, some old and some new -management implementation, hazard and human factors analysis processes, work processes,
monitoring, information and organization systems and services.
A structure and specific analytic questions to more fully utilize accident facts to improve the
system. Trials of MORT have shown an ability to assist persons from a discipline -- safety,
management, engineering, sciences or other staff specialties and experienced craftsmen -- to
quickly apply and broaden their skills in accident analysis and safety review, and have provided a
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common base for communication, cooperation, and planning for greater accident control. At the
same time, the disciplined MORT format has shown flexibility in rapid evaluation and
assimilation of new experience, judgment, findings or technology. Specific safety innovation and
acceptance methods and projects have been outlined for transition to a comprehensive,
superlative safety system -- for the long term a "safer way of life.

UNIT 3
Accident or incident investigation
An accident is an unplanned/undesired event that results in a personal injury or illness, or in
damage to property, process or the environment.
An incident is an unplanned/undesired event that has the potential to result in an injury, illness,
or property damage.
An incident usually refers to an unexpected event that did not cause injury or damage this time
but had the potential. "Near miss" or "dangerous occurrence" are also terms for an event that
could have caused harm but did not.
Please note: The term incident is used in some situations and jurisdictions to cover both an
"accident" and "incident". It is argued that the word "accident" implies that the event was related
to fate or chance. When the root cause is determined, it is usually found that many events were
predictable and could have been prevented if the right actions were taken -- making the event not
one of fate or chance (thus, the word incident is used). For simplicity, we will use the term
accident to mean all of the above events.
The information that follows is intended to be a general guide for supervisors or joint
occupational health and safety committee members. When accidents are investigated, the
emphasis should be concentrated on finding the root cause of the accident rather than the
investigation procedure itself so you can prevent it from happening again. The purpose is to find
facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply
record the steps of the event.

Reasons to investigate a workplace accident include:

most importantly, to find out the cause of accidents and to prevent similar accidents in the
future
to fulfill any legal requirements
to determine the cost of an accident
to determine compliance with applicable safety regulations
to process workers' compensation claims

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Incidents that involve no injury or property damage should still be investigated to

determine the hazards that should be corrected. The same principles apply to a quick
inquiry of a minor incident and to the more formal investigation of a serious event.
2. Philosophy must recognize the fallibility of people
Even the best people make mistakes and have a retention half-life.
Supervision is not a matter of mistrust; rather, it recognizes that people make mistakes
and proficiency decays over time.
When the consequences of failure are high (e.g., crashing, sinking, etc.), the use of a
series of checks/safety features will reduce the probability of failure.
3. Accident or incident investigation reporting and analysis
The prime objective of accident investigation is prevention. Finding the causes of an
accident and taking steps to control or eliminate it can help prevent similar accidents
from happening in the future. Accidents can rarely be attributed to a single cause. Work
environment, job constraints, and supervisory or worker experience can all play a part.
These factors must be examined to determine what role each had in causing the accident.
Once the causes are established, precautions must be identified and implemented to
prevent a recurrence. Investigators must always keep in mind that effective accident
investigation means fact-finding, not fault-finding.
To explain why and how an accident happened, investigators must collect
information on the events that took place before and during the event. Investigators can
then determine accident conditions by examining physical evidence and interviewing
witnesses. Both of these steps are of equal importance and should be done as soon as
possible to ensure complete accident investigation. Equally important is the need to
document the steps that were taken immediately after the accident to deal with the
emergency and to begin the investigation. It also identifies the forms to be used and the
procedures to be followed within specified time frames.
In order for an investigation to be a valuable tool in accident prevention, three things
must take place:
The information gathered must be analyzed;
Corrective action must be taken; and
The action must be monitored for effectiveness.
Requirements
Company health and safety programs should have the following items addressed in the
requirements regarding accident investigation:
What kinds of accidents must be investigated?
Who should investigate what?
What training should investigators have?

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Who reviews the investigation report and follows up on any observations or

recommendations?
What should be investigated: All Lost Time Injuries? All Medical Aid Injuries?
All with more than $ X in property damage? Any with a potential for serious
injury or major financial loss?

Reportable accidents
In addition to accidents that result in injury, there are legal requirements to report accidents to the
MOL. These include fatalities, critical injuries, occupational illness and the following prescribed
incidents:

A worker falling a vertical distance of three metres or more.

A worker falling and having the fall arrested by a fall arrest system other than a
fall restricting system.
A worker becoming unconscious for any reason.
Accidental contact by a worker or by a worker's tool or equipment with energized
electrical equipment, installations or conductors.
Accidental contact by a crane, similar hoisting device, backhoe, power shovel or
other vehicle or equipment or its load with an energized electrical conductor rated
at more than 750 volts. Structural failure of all or part of falsework designed by,
or required by this Regulation to be designed by, a professional engineer.
Structural failure of a principal supporting member, including a column, beam,
wall or truss, of a structure.
Failure of all or part of the structural supports of a scaffold.
Structural failure of all or part of an earth- or water-retaining structure, including
a failure of the temporary or permanent supports for a shaft, tunnel, caisson,
cofferdam or trench.
Failure of a wall of an excavation or of similar earthwork with respect to which a
professional engineer has given a written opinion that the stability of the wall is
such that no worker will be endangered by it.
Overturning or the structural failure of all or part of a crane or similar hoisting
device.

There is a legal requirement to not only report what happened, but also the steps taken to prevent
a recurrence. It is wise to investigate these events to see if they were the result of unforeseen,
isolated circumstance or if they resulted from a breakdown or oversight in the company's health
and safety program.
Regarding the other key points, the company's program should identify who should do the
investigation, the training requirements (Accident Investigation is part of several other training
programs, such as IHSA's Construction Health & Safety Rep and Basics of Supervising
Programs as well as a separate course). It should also identify who reviews the investigation

13

report and is responsible for ensuring that follow-up is done regarding any corrective
actions/deficiencies that were found.
An investigator who believes that accidents are caused by unsafe conditions will likely try to
uncover conditions as causes. On the other hand, one who believes they are caused by unsafe
acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine
some underlying factors in a chain of events that ends in an accident.
4. Accident or incident investigation purpose
The important point is that even in the most seemingly straightforward accidents, seldom, if
ever, is there only a single cause. For example, an "investigation" which concludes that an
accident was due to worker carelessness, and goes no further, fails to seek answers to several
important questions such as:

Was the worker distracted? If yes, why was the worker distracted?

Was a safe work procedure being followed? If not, why not?

Were safety devices in order? If not, why not?

Was the worker trained? If not, why not?

An inquiry that answers these and related questions will probably reveal conditions that are more
open to correction than attempts to prevent "carelessness".
5. Accident or Incident Investigation Process

Report the accident occurrence to a designated person within the organization

Provide first aid and medical care to injured person(s) and prevent further injuries or
damage
Investigate the accident
Identify the causes
Report the findings
Develop a plan for corrective action
Implement the plan
Evaluate the effectiveness of the corrective action
Make changes for continuous improvement
As little time as possible should be lost between the moment of an accident or near miss
and the beginning of the investigation. In this way, one is most likely to be able to
observe the conditions as they were at the time, prevent disturbance of evidence, and
identify witnesses. The tools that members of the investigating team may need (pencil,
paper, camera, film, camera flash, tape measure, etc.) should be immediately available so
that no time is wasted.
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6. accident or incident investigation types

The steps in accident investigation are simple: the accident investigators gather
information, analyze it, draw conclusions, and make recommendations. Although the
procedures are straightforward, each step can have its pitfalls. As mentioned above, an
open mind is necessary in accident investigation: preconceived notions may result in
some wrong paths being followed while leaving some significant facts uncovered. All
possible causes should be considered. Making notes of ideas as they occur is a good
practice but conclusions should not be drawn until all the information is gathered.
Injured workers(s)
The most important immediate tasks--rescue operations, medical treatment of the injured,
and prevention of further injuries--have priority and others must not interfere with these
activities. When these matters are under control, the investigators can start their work.
Physical Evidence
Before attempting to gather information, examine the site for a quick overview, take steps
to preserve evidence, and identify all witnesses. In some jurisdictions, an accident site
must not be disturbed without prior approval from appropriate government officials such
as the coroner, inspector, or police. Physical evidence is probably the most noncontroversial information available. It is also subject to rapid change or obliteration;
therefore, it should be the first to be recorded. Based on your knowledge of the work
process, you may want to check items such as:
positions of injured workers
equipment being used
materials or chemicals being used
safety devices in use
position of appropriate guards
position of controls of machinery
damage to equipment
housekeeping of area
weather conditions
lighting levels
noise levels
time of day
You may want to take photographs before anything is moved, both of the general area and
specific items. Later careful study of these may reveal conditions or observations missed
previously. Sketches of the accident scene based on measurements taken may also help in
subsequent analysis and will clarify any written reports. Broken equipment, debris, and
samples of materials involved may be removed for further analysis by appropriate
experts. Even if photographs are taken, written notes about the location of these items at
the accident scene should be prepared.
Eyewitness Accounts
15

Although there may be occasions when you are unable to do so, every effort should be
made to interview witnesses. In some situations witnesses may be your primary source of
information because you may be called upon to investigate an accident without being
able to examine the scene immediately after the event. Because witnesses may be under
severe emotional stress or afraid to be completely open for fear of recrimination,
interviewing witnesses is probably the hardest task facing an investigator.
Witnesses should be kept apart and interviewed as soon as possible after the accident. If
witnesses have an opportunity to discuss the event among themselves, individual
perceptions may be lost in the normal process of accepting a consensus view where doubt
exists about the facts.
Witnesses should be interviewed alone, rather than in a group. You may decide to
interview a witness at the scene of the accident where it is easier to establish the positions
of each person involved and to obtain a description of the events. On the other hand, it
may be preferable to carry out interviews in a quiet office where there will be fewer
distractions. The decision may depend in part on the nature of the accident and the mental
state of the witnesses.
Interviewing
Interviewing is an art that cannot be given justice in a brief document such as this, but a
few do's and don'ts can be mentioned. The purpose of the interview is to establish an
understanding with the witness and to obtain his or her own words describing the event:
DO...
put the witness, who is probably upset, at ease
emphasize the real reason for the investigation, to determine what happened and why
let the witness talk, listen
confirm that you have the statement correct
try to sense any underlying feelings of the witness
make short notes or ask someone else on the team to take them during the interview
ask if it is okay to record the interview, if you are doing so
close on a positive note
DO NOT...
intimidate the witness
interrupt
prompt
ask leading questions
show your own emotions
jump to conclusions
Ask open-ended questions that cannot be answered by simply "yes" or "no". The
actual questions you ask the witness will naturally vary with each accident, but there are
some general questions that should be asked each time:
Where were you at the time of the accident?
What were you doing at the time?
What did you see, hear?
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What were the environmental conditions (weather, light, noise, etc.) at the time?
What was (were) the injured worker(s) doing at the time?
In your opinion, what caused the accident?
How might similar accidents be prevented in the future?
If you were not at the scene at the time, asking questions is a straightforward approach to
establishing what happened. Obviously, care must be taken to assess the credibility of any
statements made in the interviews. Answers to a first few questions will generally show
how well the witness could actually observe what happened.
Another technique sometimes used to determine the sequence of events is to re-enact or
replay them as they happened. Obviously, great care must be taken so that further injury
or damage does not occur. A witness (usually the injured worker) is asked to reenact in
slow motion the actions that preceded the accident.

Background Information
A third, and often an overlooked source of information, can be found in documents such as
technical data sheets, health and safety committee minutes, inspection reports, company policies,
maintenance reports, past accident reports, formalized safe-work procedures, and training
reports. Any pertinent information should be studied to see what might have happened, and what
changes might be recommended to prevent recurrence of similar accidents.

7. accident and incident investigation immediate and basic causes:

Adverse events have many causes. What may appear to be bad luck (being in the wrong place
at the wrong time) can, on analysis, be seen as a chain of failures and errors that lead almost
inevitably to the adverse event. (This is often known as the Domino effect.)
These causes can be classified as:
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immediate causes: the agent of injury or ill health (the blade, the substance, the dust etc);
underlying causes: unsafe acts and unsafe conditions (the guard removed, the ventilation
switched off etc);
root causes: the failure from which all other failings grow, often remote in time and space
from the adverse event (eg failure to identify training needs and assess competence, low
priority given to risk assessment etc).
To prevent adverse events, you need to provide effective risk control measures which
address the immediate, underlying and root causes.
The domino theory
According to H.W. Heinrich (1931), who developed the so-called domino theory, 88 of all
accidents are caused by unsafe acts of people, 10% by unsafe actions and 2% by acts of God.
He proposed a five-factor accident sequence in which each factor would actuate the next step
in the manner of toppling dominoes lined up in a row. The sequence of accident factors is as
follows:

1.
ancestry
and
social
2.
worker
3.
unsafe
act
together
with
mechanical
4.
accident
5. damage or injury.

environment
fault
and

physical

hazard

9.accident and incident investigation identifying the key factors

In the same way that the removal of a single domino in the row would interrupt the sequence of
toppling, Heinrich suggested that removal of one of the factors would prevent the accident and
resultant injury; with the key domino to be removed from the sequence being number 3.
Although Heinrich provided no data for his theory, it nonetheless represents a useful point to
start
discussion
and
a
foundation
for
future
research.
Task

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Here the actual work procedure being used at the

time of the accident is explored. Members of the
accident investigation team will look for answers to
questions such as:

Was a safe work procedure used?

Had conditions changed to make the normal

procedure unsafe?

Were the appropriate tools and materials available?

Were they used?

Were safety devices working properly?

Was lockout used when necessary?

For most of these questions, an important follow-up question is "If not, why not?"
Material
To seek out possible causes resulting from the equipment and materials used, investigators might
ask:

Was there an equipment failure?

What caused it to fail?

Was the machinery poorly designed?

Were hazardous substances involved?

Were they clearly identified?

Was a less hazardous alternative substance possible and available?

Was the raw material substandard in some way?

Should personal protective equipment (PPE) have been used?

Was the PPE used?

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Were users of PPE properly trained?

Again, each time the answer reveals an unsafe condition, the investigator must ask why this
situation was allowed to exist.
Environment
The physical environment, and especially sudden changes to that environment, are factors that
need to be identified. The situation at the time of the accident is what is important, not what the
"usual" conditions were. For example, accident investigators may want to know:

What were the weather conditions?

Was poor housekeeping a problem?

Was it too hot or too cold?

Was noise a problem?

Was there adequate light?

Were toxic or hazardous gases, dusts, or fumes present?

Personnel
The physical and mental condition of those individuals directly involved in the event must be
explored. The purpose for investigating the accident is not to establish blame against someone
but the inquiry will not be complete unless personal characteristics are considered. Some factors
will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done?

Had they been adequately trained?

Can they physically do the work?

What was the status of their health?

Were they tired?

Were they under stress (work or personal)?

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Management
Management holds the legal responsibility for the safety of the workplace and therefore the role
of supervisors and higher management and the role or presence of management systems must
always be considered in an accident investigation. Failures of management systems are often
found to be direct or indirect factors in accidents. Ask questions such as:

Were safety rules communicated to and understood by all employees?

Were written procedures and orientation available?

Were they being enforced?

Was there adequate supervision?

Were workers trained to do the work?

Had hazards been previously identified?

Had procedures been developed to overcome them?

Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?

Were regular safety inspections carried out?

10.accident and incident investigation corrective action

This model of accident investigations provides a guide for uncovering all possible causes and
reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place
some of the sample questions in different categories; however, the categories are not important,
as long as each pertinent question is asked. Obviously there is considerable overlap between
categories; this reflects the situation in real life. Again it should be emphasized that the above
sample questions do not make up a complete checklist, but are examples only.
Completing report and documenting corrective actions - At this point, once youve gathered
information and interviewed the involved worker and any witnesses, you can prepare the
investigation report itself and formulate corrective actions. Your company should have
determined who the report is sent to, within what time frame and what information gets
communicated to workers, management, or gets filed or posted. Each corrective action listed

21

should have a person assigned ultimate responsibility for the action, a completion date set and a
place to mark completion of the item.
11.Incident Investigation Process Diagram
Prepare
1)Determine:
Who conducts and participates in investigation Prepare investigation kit
What incidents to investigate

Create investigation and interview forms

What information to collect

Document investigation procedures

Select and train investigators

Incident

2)Enact
Arrange for first aid or medical treatment of injured person(s)
Secure the scene

Interview injured worker and witnesses

Identify and gather witnesses

Document scene with photos or videos

Retrieve investigation kit

Collect information

3)Analyze
Review documentation

Prepare report

Identify causal factors (root causes) using the Why method

Determine corrective actions

Communicate report

4) Correct
Implement corrective actions

Share information with others

Track completion of corrective actions

Critique process for continuous improvement

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12.agencies investigating accidents

National Safety Council (NSC) was set up by the Ministry of Labour, Government of India
(GOI) on 4th March, 1966 to generate, develop and sustain a voluntary movement on Safety,
Health and Environment (SHE) at the national level. It is an apex nonprofit making, tripartite
body, registered under the Societies
Registration

Act

1860

and

the

Bombay

Public

Trust

Act

1950.

To fulfill its objective NSC carries out various activities. These include organising and
conducting specialised training courses, conferences, seminars & workshops; conducting
consultancy studies such as safety audits, hazard evaluation & risk assessment; designing and
developing HSE promotional materials & publications; facilitating organisations in celebrating
various campaigns e.g. Safety Day, Fire Service Week, World Environment Day. A computerised
Management Information Service has been setup for collection, retrieval and dissemination of
information
on
HSE
aspects.
To its credit, NSC has successfully organised many national and international conferences e.g.
XIII World Congress (1993) and XI APOSHO Conference (1995) and implemented many a
prestigious project. It also serves as a gateway to the state-of-art information on HSE aspects at
the
international
level.
In the course of its services for the last 45 years, it has built up technical expertise and
competence to meet the emerging challenges in the HSE aspects due to continuous advancements
in
technologies.
Starting with modest facilities in a very limited office accommodation provided by the Ministry
of Labour in Mumbai, it has now built with its own resources, its Headquarters & Institute
building with modern facilities in Navi Mumbai to meet the demands for its services by the
members, which have increased manifold over these years and to serve them more effectively. It
has thus joined the elite group of a few Councils in the world having their own premises.
It has been doing dedicated service to the nation in developing and leading the voluntary
movement under the able guidance of the Governing Body since 1966.

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