Accident Investigation, Analysis and Reporting Course Outline

Accident Investigation, Analysis
and Reporting
Engr. Alexander B. Trillana

OSH Consultant
Course Outline
Objectives
Definition
Types of Accident/Incident
Types of Accident/Incident Requiring
Investigation Report to DOLE
Why Should Workplace Accidents be
Conducted?
Effects of Accidents
Accident Ratio Study
Cost/Insurance Iceberg
Accident Causation Model
Accident Result
Accident/Incident Contact
Immediate Causes
Basic Causes
5 Steps of Accident/Incident Investigation
Investigators Qualification
Investigation Grab Kit
Table Top Exercises Frank Bird, 1969
2
Objectives
Explain the meaning and impact
of accidents;
Identify different types of
accident causes;
Know the purpose of accident
investigation;
Explain how to conduct an
accident investigation;
Know how to document accident
investigations; and
To provide supervisors
information and tools to
investigate employee accidents
thoroughly to prevent them from
happening again.
Introduction
Piper Alpha (1988) - 167 died
maintenance error
inexperience
poor maintenance
procedures
communications
breakdown
permit to work system
fault
safety procedures not
practice
poor emergency
response decision
Play Movie
What is an Accident?
An unplanned, undesired,
unexpected and
unwelcomed event which
interrupts normal activity
event that results in
death, injury or property/
environmental damage;
and
Accidents are the result of
the failure of people,
equipment, materials, or
environment to react as
expected;
A definition of an Incident
9
What Is An Accident?
Rig Fire...
11
What is an Accident?
An unplanned, undesired,
unexpected and
unwelcomed event
An unplanned, undesired
event that under slightly
different circumstances
could have resulted in
injury to people, damage
to equipment or pollution
of the environment
Another definition of an Incident
Types of Accidents Requiring an Investigation
Fatality or Death
Lost Time Accident or Lost work day
Restricted Work Cases or Light Duty
Medical Treatment Cases
First Aid Cases
Major property damage
Near-miss incidents with potential for
serious injury or major property damage
15
Types of Accidents Requiring an Investigation/Incident
Report to DOLE
Types of Property
Damages for Reporting
to DOLE:
Explosions of boilers,
air receivers,
Collapse of crane,
derrick, hoist
Fire causing damage
to any room where
persons are employed
-Rule 1053.02
16
Types of Accidents Requiring an Investigation/Incident
Report to DOLE
Reporting Requirements
Accidents resulting in death
or permanent total disability
must be initially reported to
DOLE within 24 hours of
occurrence.
All other Types of Injuries
such as NLTAs, RWCs, FACs
for reporting on or before
20th day of the following
month using form IP-6
-Rule 1053.01 OSHS
17
Why should workplace accidents be investigated?
To prevent
reoccurrence;
To determine the cost
associated with an
accident;
To determine
compliance with
applicable safety
regulations; and
To process workers
compensation claims.
18
Why should workplace accidents be investigated?
Effective accident
investigations
contribute to the
safety mindset of the
workplace.
Who Should Investigate Accidents?
Safety committee
members
Immediate supervisor
Department manager
Safety officer
Other safety & health
professional
20
1. On the Victim
2. On the Supervisor
3. On the Company
4. On the Nation
1. The Victim
Death
Pain & suffering
Permanent disability
Effects on family & dependants
Loss of earnings
Extra expenditure
Inability to resume occupation
Psychological effects
Feeling of uselessness
Fear of further injury
Social effects
Loss of sports or hobby
Who depends on me to come home safe?
Come home safe honey!
2. The Supervisor
loss of trained worker
loss of production
extra work
investigations & reports
training new employee
loss of prestige by:
management
other workers
effects on promotion
worry (could I have prevented it ?)
Stress
3. The Company
loss of trained worker
loss of production
damage to machinery
damage to equipment
wasted materials
increased insurance premiums
prosecutions
fines
civil actions
legal costs
loss of prestige - customers
4. The Nation
loss of section of
workforce
loss of production
increased cost of
production
effects on imports
effects on exports
effects on balance of trade
the community pays !
Serious or Disabling
Includes disabling & Serious Injuries
1
Minor Injuries
Any reported injury less than serious
10
Property Damage & Accidents
All Types
30
Accidents with no visible
Injury or Damage
600 (Critical Incidents)
Frank Bird, 1969
Serious Injury or Death

Most Accident 1
Investigations
Conducted
29
Biggest
Minor Injury
percentage
of injury-causing
Few Investigations potential!
Conducted
300
Near-Miss
3,000
Unsafe Acts, Behaviors or Conditions
Heinrichs Theory 29
R. Skiba, Germany, 1999

1 Major injury or illness
Minor injuries or
7 illnesses
No injury/illnesses
189 incidents
HSE, UK, 2000

Major incident
1
Minor incidents
5
Near misses
(think of them as
60 near hits)
US Incident Ratio
(10 Year Average, 1995-2005)
Cost of an Accident
Cost/Insurance Iceberg
(Bird, Germaine)
Direct Cost
Injury & Illness Cost

medical cost
$1
compensation cost Insured Cost
Indirect Cost
building damage
tool & eqpt damage $5 - $50
product & material damage Ledger cost of
production delays property damage
legal expenses (uninsured)
emergency expenses
interim equipment rental
investigation time
wages for lost time
cost of hiring or training $1 - $3
new worker Uninsured
extra supervisory time
miscellaneous
decrease in output of
injured costs
loss of business or
goodwill
Basic Work Accident Causation Model
Management Safety Policy & Decisions

Basic Causes Supervisory Performance
Personal Factors
Job Factors
Human Factor
Immediate causes Unsafe Unsafe
[Symptoms] Acts Conditions
ACCIDENT
unplanned release of energy
Incident Contact and/or
hazardous material
Personal injury
Accident Results Property damage
Uninsured Costs
Basic Work Accident Causation
1. Accident Results
Physical Harm
(Injury or illness) Property damage
catastrophic catastrophic
(multiple deaths) major
death serious
disabling, lost time, minor
major
serious
minor
notifiable
compensable
2. Incident Contact
Exposure (radiation, Caught on (sumabit)
gases, dust, etc) Caught between
Contact by (liquids, (naipit parte ng
chemicals, etc) katawan)
Trapped in (nakulong
Struck by (hard objects, buong katawan)
etc)
Same level fall
Contact with (nadapa)
(electricity, hot surface, Different level fall
aniamal, insect, etc) (nahulog)
Struck against (strong Over exertion
impact) (napuwersa, bumigay)
3. Immediate Causes
Unsafe Acts/Practices Unsafe Conditions
Operating equipment Inadequate protective
without authority equipment
Operating at improper speed Defective tools,
Removing safety devices equipment, materials
Failure to use Poor housekeeping
PPE/warn/secure/follow Inadequate ventilation
procedures
Congested or restricted
Horseplay action
Under influence of
alcohol/drugs
Improper
loading/lifting/placement
Unsafe Acts and Conditions

Unsafe Act
Violation of established safety
policies/procedures which could result in
an incident.
Unsafe Condition
A mechanical or physical condition which if
not eliminated, guarded or altered could
result in and incident.
Unsafe Act or
Unsafe
Condition?
41
Unsafe Act or
Unsafe
Condition? 42
Unsafe Act or
Unsafe
Condition?
43
Unsafe Act or Unsafe
Condition?
44
Is This Caused by Unsafe Act or Unsafe Condition?
Is This Caused by Unsafe Act or Unsafe Condition? 46
Is This Caused by Unsafe Act or Unsafe Condition?
Unsafe Act or
Unsafe
Condition? 48
Unsafe Act or
Unsafe
Condition?
49
Thats why mandatory no horseplaying!
Unsafe Act or
Unsafe
Condition?
Unsafe Act or
Unsafe
Condition?
51
Unsafe Act or
Unsafe
Condition?
52
Unsafe Act or
Unsafe Condition?
53
Unsafe Act or
Unsafe
Condition? 54
Unsafe Act or Unsafe Condition?
Condition Exit access Act Individual set up

blocked/obstructed. scaffolding unsafely, no
PPE, no fall protection.
55
Act
Individual
standing on
ladders he set
up unsafely.
56
Unsafe Act or
Unsafe
Condition? 57
Unsafe Act or
Unsafe
Condition?
Falling from
ladder may be
fatal!
Condition?
Without buddy is
fatal!
Unsafe Act or
Unsafe Condition?
How could we
improve this
situation?
Condition?
How could we
improve this
situation?
Condition?
How could we
improve this
situation?
Unsafe Act or
Unsafe
Condition?
63
Unsafe Act or
Unsafe
Condition?
How could we improve

this situation? 64
Unsafe Act or
Unsafe
Condition?
Falling from
treadmill may
cause serious
injury?
Unsafe Act or
Unsafe
Condition?
66
Condition?
Unsafe Act or
Unsafe
Condition?
68
Unsafe Act or
Unsafe Condition?
69
Unsafe Act or
Unsafe Condition?
70
Unsafe Act or
Unsafe Condition?
Unsafe Act or
Unsafe Condition?
72
Unsafe Act or
Unsafe Condition?
Unsafe Act or
Unsafe Condition?
Unsafe Act or
Unsafe Condition?
WELDING
ACTIVITY 75
GRINDING
ACTIVITY
Condition?
WSO 76
GRINDING
ACTIVITY
Condition?
77
Unsafe Act or
Unsafe Condition?
Unsafe Act or
Unsafe Condition?
79
Is This Caused By Unsafe
Act or Unsafe Condition?
80
Falling object
can really
hurt us!
82
Is This Caused By
Condition?
83
84
Condition Open
access hatch (fall
hazard).
85
Condition?
86
Condition?
Condition?
How about this? Unsafe Act or Unsafe Condition?
Condition?
Condition?
92
Condition?
Condition?
Condition?
Condition?
Condition?
Condition?
Condition?
Condition?
Unsafe Acts:
Cause 90% of ALL incidents *
Unsafe Conditions:
Cause 10% of ALL incidents
*Industrial Safety and
Health Management;
Liberty Mutual , 1995
Unsafe Acts vs Unsafe Conditions

*Industrial Safety and Health Management by C.
Ray Asfahl cites H.W. Heinrich, whose research
concluded that 88% of all industrial incidents are
from unsafe acts. A 1995 survey completed by Liberty
Mutual of 400 Risk Managers and Safety Consultants
found that, excluding acts of God, 92% of all
workplace incidents result from performance
deficit (unsafe behavior).
*Industrial Safety and Health Management;
Liberty Mutual , 1995
4.Basic Causes
Personal Factors Supervisory Performance
lack of knowledge or skill inadequate instructions
improper motivation failure of SOPs
physical or mental conditions rules not enforced
literacy or ability hazards not corrected
Job Factors devices not provided
physical environment Management Policy &
sub-standard equipment Decisions
abnormal usage set measurable standards
wear & tear measure work in progress
inadequate standards evaluate work-v-standards
design & maintenance correct performance if nec
purchasing standards
5 STEPS OF ACCIDENT INVESTIGATION
GATHER THE FACTS

REVIEW THE FACTS TO FIND CAUSES
DOCUMENT FINDINGS AND ACTIONS
TAKE PREVENTATIVE ACTION
FOLLOW-UP
1. GATHER THE FACTS
Answers what happened

Look at the accident scene
Record information: who, what, when, and
where
Preserve the accident scene and any
evidence
Interview witnesses independently
Ask open ended questions
THINGS TO CONSIDER WHEN FACT FINDING

Environment/facility
Equipment, clothing, personal protective
equipment (PPE)
Procedures/practices
Training - in procedures and safety
Employee readiness mental and physical
2. REVIEW THE FACTS TO FIND CAUSES

Answers why it happened
Review all the information you gathered

List all possible causes (direct, indirect, basic)
Identify all the contributing factor(s)
CAUSES
Incident-Contact - the actual energy
(movement or source) that caused injury to
employee. If this energy wasnt present, the
injury would not have occurred.
Immediate Causes - any unsafe acts or
conditions that contribute to the injury
occurring.
Basic Causes - policies, procedures,
environment or personal factors that
contribute to the injury occurring.
3. DOCUMENT FINDINGS AND ACTIONS
Complete the INCIDENT REPORT

State only the facts in the incident report (no opinions)
4. TAKE PREVENTATIVE ACTION(S)
Corrective actions must address the cause(s) of

the accident
Look for both short-term and long-term
solutions
Include dates for completion of the corrective
actions and identify those responsible
Report corrective actions to the safety
committee
4. TAKE PREVENTATIVE ACTION(S)
Hierarchy of Controls
Most effective
Eliminate
Substitute
Engineering
Admin
Training
PPE Least effective
Emergency Response
5. FOLLOW-UP
Follow-up to ensure that corrective action has

been taken and is effective at reducing
accidents
Monitor the progress of both short-term and
long-term corrective actions.
Investigators Qualification
Technical Knowledge
Objectivity
Analytical approach to
problems
Familiarity with the job,
process or operation
Tact in communicating
Intellectual honesty
Inquisitiveness &
curiosity
Investigation Grab Kit
clipboard, paper (including specimen containers
graph) and pens magnifying glass
camera compass
tape measure danger tags
cassette recorder & spare yellow crayon
tapes
orange fluorescent spray
accident investigation report paint
forms
torch with batteries
hi-viz barrier tape for scene
preservation hi-viz orange vest
first aid kit hearing & eye protection
identification tags for parts plastic containers for samples
gloves (industrial & medical) paper rolls or towel
safety helmet
Accident Prevention
Accidents can be
prevented by early
detection,
reporting and
abating!
WEED OUT THE CAUSES OF INJURIES
AND ILLNESSES
Injury/Illness
Surface Causes of the

Accident
Unsafe Conditions Unsafe Acts

Lack of time Fail to enforce
Root Causes of Inadequate training

the Accident
No discipline procedures
No orientation process Outdated procedures
Inadequate training plan
No accountability policy No inspection policy
If you eliminate the root cause of an accident, you will eliminate

those accidents in the future!
Ishikawa Diagrams (Fishbone Diagrams)
People Equipment
Management Material Environment
Brainstorm causal factors within each category (bone)

Continue asking why until complete
Direct & Indirect Causes
Technique
INCIDENT: Slip/Fall to Floor Fracture Right Arm

DIRECT Cause = Slip/Fall same level
INDIRECT Cause = Oil on Floor; Employee running
Employee Was Running Oil Left on Floor

Unsafe Act Unsafe Condition
Employee In A Hurry Oil Not Cleaned Up Defective Forklift

Unsafe Act Unsafe Act Unsafe Condition
Production/Safety Workplace Procedures Daily Inspections not

No PM Program
Demands Unequal Not Defined completed
Unsafe Condition
Unsafe condition Unsafe Condition Unsafe Action
Supervisors role is to identify direct and indirect causes. This will help
management identify, target, and correct potential root causes.
Other Root Cause of
Accidents
119
Other Root Cause of Accident
124
Other Root Cause
of Accident
TABLE TOP EXERCISE
Preventing Accident
Divide the participants into 4 groups.
Group brainstorming, analyze the assigned

previous accident scenario, establish your
appropriate controls to prevent its recurrence
.
Select your best presenter and discuss.

Types of Accidents
Exposure Accident
Two workers assigned to monitor the boiler
were overcome by CO gases when the vapors
from the boiler engine accumulated in the
boiler room. The ventilation blower was not
working properly.
Conduct a detailed investigation in-order to

identify the incident-contact, immediate
causes and basic causes?
Group 1 127
Types of Accidents
Different Level Fall Accident:
A worker was standing on a platform 12 feet

above ground replacing a guard on the motor
of a bucket elevator. The platform did not have
a railing around it. When he stepped back he
fell of the platform.

identify the incident-contact, immediate
causes and basic causes?
Group 2
128
Types of Accidents
A truck driver was using

Contact-By Accident: compressed air to unload
acid into a storage tank.
During the process the
unloading hose burst
spraying him and other
workers with acid.
Conduct a detailed
investigation in-order to
identify the incident-
contact, immediate causes
and basic causes?
Group 3
Types of Accidents
Trapped-In Accident:
A worker entered a lateral section of sewer pipe
to inspect the lining. When he reached a vertical
section he fell inside and was unable to climb out.
He was rescued by using a retrieval line.
identify the incident-contact, immediate causes
and basic causes?
Group 4
130
Types of Accidents
Contact With Accident:
A worker was erecting a steel beam outside

the maintenance shop. While lifting the beam,
the beam made contact with overhead
electrical wires. He suffered serious electrical
burns.

identify the incident-contact, immediate causes
and basic causes?
Group 5 131
Accident Investigation, Analysis
and Reporting
THANK YOU VERY MUCH
Engr. Alexander B. Trillana

OSH Consultant

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Accident Investigation, Analysis

Engr. Alexander B. Trillana

Serious Injury or Death

R. Skiba, Germany, 1999

1 Major injury or illness

HSE, UK, 2000

Injury & Illness Cost

Management Safety Policy & Decisions

Unsafe Acts and Conditions

Unsafe Act or Unsafe Condition?

Condition Exit access Act Individual set up

How could we improve

Unsafe Act or Unsafe Condition?

Unsafe Acts vs Unsafe Conditions

GATHER THE FACTS

1. GATHER THE FACTS

Answers what happened

THINGS TO CONSIDER WHEN FACT FINDING

2. REVIEW THE FACTS TO FIND CAUSES

Review all the information you gathered

3. DOCUMENT FINDINGS AND ACTIONS

Complete the INCIDENT REPORT

4. TAKE PREVENTATIVE ACTION(S)

Corrective actions must address the cause(s) of

4. TAKE PREVENTATIVE ACTION(S)

PPE Least effective

Follow-up to ensure that corrective action has

Surface Causes of the

Unsafe Conditions Unsafe Acts

Root Causes of Inadequate training

Inadequate training plan

No accountability policy No inspection policy

If you eliminate the root cause of an accident, you will eliminate

Management Material Environment

Brainstorm causal factors within each category (bone)

INCIDENT: Slip/Fall to Floor Fracture Right Arm

Employee Was Running Oil Left on Floor

Employee In A Hurry Oil Not Cleaned Up Defective Forklift

Production/Safety Workplace Procedures Daily Inspections not

Divide the participants into 4 groups.

Group brainstorming, analyze the assigned

Select your best presenter and discuss.

Conduct a detailed investigation in-order to

Different Level Fall Accident:

A worker was standing on a platform 12 feet

Conduct a detailed investigation in-order to

A truck driver was using

A worker was erecting a steel beam outside

Conduct a detailed investigation in-order to

THANK YOU VERY MUCH

Engr. Alexander B. Trillana

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