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Investigation
WHAT IS AN ACCIDENT?
What is an accident?
o Any unexpected event
o Some may even be good
Does an accident always involve an
injury?
Does an injury always involve an
accident?
What Is An Accident?
Accidents
Accident
o Any unplanned event that results in
Personal injury
Property damage
Accidents
Usual causes
o Failure of people, equipment, supplies, or
surroundings to behave or react as
expected
WHY INVESTIGATE?
Why investigate?
o To PREVENT injuries
Investigations should not be witch
hunts
o If results show need for discipline, fine
But.....
o That is not the purpose
INVESTIGATIONS
Include non injury accidents incidents
o Proactive
o Preventative
Investigating only injuries
o Reactive
INJURY PYRAMID
Fatality
Serious
Recordable
Recordable
Non-injury Accidents
Incident Investigation Plan
Establish parameters
Be aware of other requirements
o ADA, EEO, Union, etc.
Establish procedures
Develop forms
Train employees
First Report
Indirect
Causes Unsafe Act Unsafe Condition
Direct
Causes Unplanned Release of Energy
and/or Hazardous Material
Incident
The Investigation
Investigate the scene
o Take measurements
o Take pictures
o Evaluate equipment
o Be imaginative
The Investigation
Look for
o Guards off
o Lack of PPE
o Housekeeping issues
o Poor work practices
o Faulty equipment
o Inadequate training
o Poorly written procedures
o Etc.
Interviews
Interview employee involved
Interview witnesses
Interview other employees in area
Look for similar incidents
Interviews
Explain the purpose of the investigation
o Accident prevention
Put at ease
Let speak freely
Take notes without distracting
Only use a tape recorder with the
persons knowledge and consent.
Interview as soon as possible
Analysis Techniques
Change analysis
Job Safety Analysis (JSA)
Event and Causal Factors Analysis
Multi linear Events Sequencing (MES)
Project Evaluation Tree (PET)
Combination
Report of Investigation
1. Background
information
2. Detailed account
of the incident
3. Resolution
4. Corrective actions
RESOLUTION
Discuss ways of preventing future
incidents
Solicit ideas from employees & others
Be creative
Make recommendations
Corrective Actions
Corrective actions
o Recommendations that are adopted
Inform and train employees and
supervisors
Follow-Up
Involve supervisors & employees
Are solutions:
o Used?
o Effective?
Solicit feedback
Trend Analysis
Evaluate for incident, accident and
injury trends in order to focus efforts
Use 300 forms, incident & accident
reports, first aid logs, inspection
reports, etc.
Analyze by entity, facility, time, job, etc.
Do at least a 3 year comparison
Resource
Ask for help from your workers
compensation carrier
Sandra A. Mihalik, WSO-CST
Safety & Health Specialist
Montana Safety & Health Bureau
Phone: 406.444.6418
E-mail: smihalik@mt.gov