Introduction

• Incidents or accidents should be properly

investigated to establish the cause of accident and
allow an organization to take the appropriate action
and prevent similar events from occurring.
• Good investigation is a key element in making
improvements in health and safety performance.
• Investigations forms part of the monitoring system –
reactive monitoring
 Definition
What is an accident
• The term "accident" is any undesired
circumstances which give rise to:
• Ill health or injury;
• Damage to property, plant, products or the
environment;
• Production loses or increased liabilities
(Hughes & Ferrett:2011)
 Definition
• An incident usually refers to an undesired
circumstances and ‘near misses‘ which could
cause accidents or an 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.
 Definition
• NB: The term incident is used in some
situations and jurisdictions to cover both an
"accident" and "incident".
 Definition
Accident investigation:
• A “Systematic Observation, Analysis and
Evaluation of Events that have occurred which
have caused damage to People, Property and
Product OR had the potential to do so“.
 Purpose of Investigating
• 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
- To eliminate future accidents
 Purpose of Investigating
• Benefits of accident investigations:
- Prevents similar events from occurring
- Prevents business losses
- Improves the management skills to improve
health and safety performance throughout the
organization
- Improve the moral of the employees
 Duties of the Employer
• The managers need to :
- Communicate the type of accident or incident
that needs to be reported
- Provide a system for reporting and recording
- Ensure proper reports are being made
- Make appropriate records of accidents and
incidents
- Investigate accidents and incidents reported
 Duties of the Employer
- Monitor the system to make sure that it is
working effectively
- Analyze and interpret the data to check for the
trends in performance and the prevalence of
types of incidents or injury
 Types of Accidents
• Types of Accidents or Adverse Events
1. Accident: an event that results in injury or ill health
2. Incident:
- Near miss: an event that, while not causing harm, has
a potential to cause injury or ill health. Also includes
dangerous occurrences
- Undesired circumstances: a set of conditions or
circumstances that have the potential to cause injury
or ill health
 Types of Accidents
3. Dangerous occurrence: one of the number of
specific, reportable adverse events, as
defined in the Reporting of Injuries Diseases
and Dangerous Occurrences Regulations
1995(RIDDOR)
4. Immediate cause: the most obvious reason
why an adverse event happens, e.g. the
guard is missing; the employee slips etc
 Types of Accidents
5. Root cause: an initiating event or failing from
which all other causes or failings spring. Root
cause are generally management, planning or
organizational failings.
6. Underlying cause: the less obvious ‘system' or
‘organizational’ reason for an adverse event
happening, pre-start-up machinery checks are
not carried out by the supervisor; the hazard has
not been adequately considered via a suitable
and sufficient risk assessment
 Consequences of an Accident
1. Fatal: work related death
2. Major Injury/ill health: include fractures,
amputations, loss of sight, a burn or penetrating
injury to eye, any injury or acute illness resulting
in unconsciousness, requiring resuscitation or
requiring admittance to hospital for more than
24 hours
3. Serious injury/ill health: where the person
affected is unfit to carry out his normal work for
more than three consecutive days
 Consequences of an Accident
4. Minor injury: all other injuries, where the
injured person is unfit for his normal work for
less than three days
5. Damage only: damage to property,
equipment, the environment or production
losses
Accidents and Incident Investigated
• Minimal Level investigation- relevant
supervisor will look cause of the accident and
try and come up with the preventative
measures to prevent future accidents
• Low Level investigation- short investigation by
the relevant supervisor into the circumstances
and the immediate underlying and root cause
of the accident to prevent future accidents
Accidents and Incident Investigated
• Medium - level investigation involves more
detailed investigation by the relevant supervisor,
or line manager, health and safety advisor, and
employee representatives
• High- level investigation involves team based
investigation, involving supervisor, health and
safety advisers and employee representatives. It
is carried out under the supervision of senior
management or directors
 Who should do the investigation?
• Ideally, an investigation would be conducted by
someone experienced in accident causation,
experienced in investigative techniques, fully
knowledgeable of the work processes, procedures,
persons, and industrial relations environment of a
particular situation.
• Some jurisdictions provide guidance such as requiring
that it must be conducted jointly, with both
management and labour represented, or that the
investigators must be knowledgeable about the work
processes involved.
 Who should do the investigation?
• In most cases, the supervisor should help investigate the
event. Others with sufficient status and knowledge to make
recommendations that will be respected by the
organization and members of the team can include:
• Employees with knowledge of the work
• Safety officer
• Health and safety committee
• Union representative, if applicable
• Employees with experience in investigations
• “Outside" expert
• Representative from local government
 Who should do the investigation?
• The department Manager should lead the
investigation and the reasons are as follows:
- Know about the situation
- Know about the employees
- Has an interest in the prevention of further
incidents /accidents
- Able to communicate most effectively with
the other employees concerned
 Who should do the investigation?
- Take immediate action to prevent a similar
incident
- Demonstrate practical concern for employees
and control over the immediate work situation
 Incident Investigation Procedure
• The investigation should be carried as soon as
possible after the accident to allow the
maximum amount of information to be
obtained
• The aim of the investigation is to explore the
situation for possible underlying factors
 Incident Investigation Procedure
• Advantages of immediate investigation
- Factors are fresh
- Witness has had less time to talk
- Physical conditions have not yet changed
- More people are likely to be available
- To take immediate action to prevent a
recurrence
- To get immediate information from the person
who was involved in the accident
 Source of information
• Gather the information from all the available
sources e.g.
- witness,
- Supervisor,
- Physical condition,
- Hazard data sheets,
- Written systems of work,
- Training records
 Initial Action
• The line manager must take charge , directing
and approving every thing that is done
• Ensure the provision of first aid and call for
emergency services
• Control potential secondary events
• Identify sources of evidence at the scene
• Preserve evidence from alteration or removal
• Notify appropriate site management
 Investigation Method
• Four basic elements to a sound investigations:
- Collect facts about what has happened
- Assemble, and analyze the information
abtained
- Compare the information with acceptable
industry and company standards and legal
requirements to draw conclusions
- Implement the findings and monitor progress
 Investigation Method
• Investigation has three facets:
- Direct observation of the scene
- Documents including written instructions,
training records, procedures, safe operation
systems, risk assessment, polices, records of
inspections, etc
- Interviews with persons injured, witness etc
 Interview techniques
• Aim of the interview is to discover facts and
use them to prevent future similar accidents
• Witness should be given the opportunity to
explain what happened in their own way and
should avoid interruptions
• Questions should be asked to elicit more
information and try to avoid why ? Questions.
Type of questions should be asked

• What?
• When?
• Where?
• Who?
• How?
 What should an investigation look
at ?
1. The Immediate causes that have been
manifested in the incident or accident
- Personal factors (unsafe acts, training and
competence)
- Task factors (unsafe conditions, ergonomic
factors, normal working practices and actual
working methods)
2. Underlying cause: less obvious systems
 What should an investigation look
at ?
• Root cause- where failings arise and are
generally :
- Management,
- Planning,
- Organizational failings which include policy
and procedures ,quality of communication,
deficiency in risk assessment, plans and
control systems, inadequate M&E etc
 What should an investigation look
at ?
3. Compare with the relevant standards to see
if: - Suitable and available to cover legal
standards and the controls required by the
risk assessment
- Standards are available to the organization
- Standards were implemented in practice and
why there was a failure and if changes could
be made to the standards
 What should an investigation look
at ?
4. Root cause analysis using the five whys? For the
minimum or low level of investigation
- You keep asking the why until you reach I do not
know and then you circle the last reason
 Root Cause Analysis Technique
• For each obstacle, ask “why is this happening?”
• For each answer, ask “why” again?
• Record all responses as they come up
• Keep asking “why?” until there are no more
reasons
• Stop when you say “I don’t know” or when you
have reached the 5th why?
• The root cause is the lowest-level cause you can do
something about.
 Benefits of asking the FIVE whys
- Simplicity
- Effectiveness- quickly separates the symptoms from
the causes and identify the root cause of the
problem
- Comprehensive - it determines the relationships
between various problem causes
- Flexibility –works well alone
- Engaging – it fosters teamwork
- Inexpensive – no additional costs
What should an investigation look
at ?
• For the more complex methods you have to
use the Tree of Causes
 Example of Root Cause Analysis
Obstacle: Supervisors are not making appropriate number of supervision rounds

Why? Why?
Did not know how many visits were expected No transport
Why? Why?
Why? Why?
Have no job No one told them Not in their
description training No funds

Why? Why?
Why? Why?
No one’s job I don’t
No one developed a to tell them Did not request funds
know
Job description
Why? Why?
Have no supervisor Did not know how to complete
the funding request form
I don’t
Why? Why?
know No support system for them
Why?
Were not trained
Why?
Why?
I don’t know I don’t know
 Recording and reporting
• Investigations should have highlighted both
the immediate and the underlying causes
• Come up with the recommendations with
priorities both for the immediate action and
for longer term improvements
• The report should go further up to the
management chain if the improvement
recommendations require authorization
 Recording and reporting
• Make sure that a follow up is made to check
on the implementation of the
recommendations and also review the effect
of the recommendation
• The report should also generate the safety
awareness and report should be circulated to
the relevant people in the origination when
appropriate
 Investigation forms
• Accident/incident form consists of the
following:
- Date and location of the accident
- Circumstances of the accident/incident
- Immediate cause of the accident/incident
- Underlying cause of the accident/incident
- Immediate action taken
- Recommendation for further improvements
 Investigation forms
- Report circulation list
- Date of investigation
- Signature of investigating team leader
- Names of investigating team
• Follow-up
- Were the recommendations implemented
- Were the recommendations effective
 Recording and Reporting
• Any one injured at work is required to inform
the employer and record the information in an
incident book and include a statement on how
an accident happened

• Employer will then do the investigation to find

the cause of the accident
 Recording and Reporting
• When an employee or a public member is
killed or taken to hospital, the responsible
person must notify the enforcing authority
without delay by the quickest practicable
means e.g. Telephone
 Recording and Reporting
• Over three day lost time injury- if any person
working in the premises suffers an injury and
is away from work for more than three days,
the responsible person must report to the
enforcing authority within 10 days
• If an employee suffers from a reportable work
related disease must be reported to the
enforcing authority within 10 days.
 Recording and Reporting
• A disease report form, F2508A must be filled
and sent to enforcing authority
• All dangerous occurrences must be reported
immediately to the authority
• Forms used
- F2508- for accidents
- F2508A- for reportable disease
- 2508DO- for dangerous occurrences
 Recording and Reporting
• F2508GI or F2508G2 for reportable gas
incident
• Organization must keep the records in any
form they wish e.g.
- Keep copies of report forms in file
- Details on computer
- Incident book entry
- Maintaining a written log
 Major Injuries
• Fractures:
• Except in finger, thumbs or toes
• Dislocation:
• Shoulder, hip, knee or spine
• Amputation
• Eyes:
• Loss of sight, penetration, chemical or metal burn
• Loss of consciousness
 Major Injuries
• Illness:
• Requiring medical treatment caused by exposure
to chemical or pathogens
• Admission to hospital for more than 24 hours
 Calculation of Injury Incidence
Rates
• Number of Reportable Accidents
x 100,000
• Average number employed during year
 Lost Time
• Lost Time Injury occurs when an employee is
injured in the execution of his/her duties and
as a result of this injury or work-related illness
is unable to perform his/her regular duties for
one full shift or more than one day following
the day which the injury was incurred