Accident Investigation

Accident analysis is carried out in order to determine the cause or causes of an accident or series of accidents so
as to prevent further incidents of a similar kind. It is also known as accident investigation. It may be performed by
a range of experts, including forensic scientists, forensic engineers or health and safety advisers. Accident
investigators, particularly those in the aircraft industry, are colloquially known as "tin-kickers"

Sequence

Accident analysis is performed in four steps:

Fact gathering: After an accident happened a forensic

process starts to gather all possibly relevant facts that may
contribute to understanding the accident.
Fact Analysis: After the forensic process has been completed
or at least delivered some results, the facts are put together to give
a "big picture." The history of the accident is reconstructed and
checked for consistency and plausibility.
Conclusion Drawing: If the accident history is sufficiently
informative, conclusions can be drawn about causation and
contributing factors.
Counter-measures: In some cases the development of
counter-measures is desired or recommendations have to be issued
to prevent further accidents of the same kind.
Methods
There exist numerous forms of Accident Analysis methods. These can be divided into three categories:
Causal Analysis uses the principle of causality to determine the course of events. Though people casually speak of
a "chain of events", results from Causal Analysis usually have the form of directed a-cyclic graphs the nodes
being events and the edges the cause-effect relations. Methods of Causal Analysis differ in their respective notion
of causation.

Expert Analysis relies on the knowledge and experience of

field experts. This form of analysis usually lacks a rigorous
(formal/semi formal) methodological approach. This usually affects
falsify-ability and objectivity of analyses. This is of importance when
conclusions are heavily disputed among experts.
Organizational Analysis relies on systemic theories of
organization. Most theories imply that if a system's behavior stayed
within the bounds of the ideal organization then no accidents can
occur. Organizational Analysis can be falsified and results from
analyses can be checked for objectivity. Choosing an organizational
theory for accident analysis comes from the assumption that the
system to be analysed conforms to that theory.
In any business or organisation things dont always go to plan. You need to prepare to deal with unexpected
events in order to reduce their consequences. Workers and managers will be more competent in dealing with the
effects of an accident or emergency if you have effective plans in place that are regularly tested.
You should monitor and review any measures you have put in place to help control risk and prevent accidents and
incidents from happening. Findings from your investigations can form the basis of action to prevent the accident
or incident from happening again and to improve your overall risk management. This will also point to areas of
your risk assessments that need to be reviewed.
An effective investigation requires a methodical, structured approach to information gathering, collation and
analysis.

Why investigate?

Health and safety investigations form an essential part of the monitoring process that you are required to carry out. Incidents, including near
misses, can tell you a lot about how things actually are in reality.
Investigating your accidents and reported cases of occupational ill health will help you uncover and correct any
breaches in health and safety legal compliance you may have been unaware of
The fact that you thoroughly investigated an incident and took remedial action to prevent further occurrences would
help demonstrate to a court that your company has a positive attitude to health and safety

Your investigation findings will also provide essential information for your insurers in the event of a claim
An investigation can help you identify why the existing risk control measures failed and what improvements or additional measures are needed.
It can:
provide a true snapshot of what really happens and how work is really done (workers may find short cuts to make their
work easier or quicker and may ignore rules - you need to be aware of this)
improve the management of risk in the future
help other parts of your organisation learn
demonstrate your commitment to effective health and safety and improving employee morale and thinking towards
health and safety
Investigating near misses and undesired circumstances, where no one has been harmed, is as useful as, and may be easier than, investigating
accidents.
In workplaces where a trade union is recognised, appointed health and safety representatives have the right to:
investigate potential hazards and dangerous occurrences in the workplace
examine causes of workplace accidents

Reporting incidents

All employers, the self-employed and people in control of work premises have duties under the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR).
They must report certain work-related injuries, cases of ill health and dangerous occurrences. RIDDOR applies to all work activities but not all
incidents are reportable.
Reporting incidents should not stop employers undertaking their own investigation to ensure risks are controlled effectively.

Accident Investigation The Six Key Questions

Question 1: WHO
Who
Who
Who
Who
Who

was injured? Who saw the accident?

was working with him/her?
had instructed/assigned him/her?
else was involved?
else can help prevent recurrence?

Question 2: WHAT
What
What
What
What
What
What
What
What
What
What
What
What
What
What
What
What
What
What
What

was the accident?

was the injury?
was he/she doing?
had he/she been told to do?
tools was he/she using?
machine was involved?
operations was he/she performing?
instructions had he/she been given?
specific precautions were necessary?
specific precautions was he/she given? Did he/she use?
protective equipment was he/she using?
had other persons done that contributed to the accident?
problem or question did he/she encounter?
did he/she or witnesses do when accident occurred?
extenuating circumstances were involved?
did he/she or witnesses see?
will be done to prevent recurrence?
safety rules were violated?
new rules are needed?

Question 3: WHEN
When
When
When
When
When
When

did the accident occur?

did he/she start on that job?
was he/she assigned to the job?
were the hazards pointed out to him/her?
had his/her supervisor last checked on job progress?
did he/she first sense something was wrong?

Question 4: WHY
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why

was he/she injured?

did he/she do what he/she did?
did the other person do what he/she did?
wasnt protective equipment used?
werent specific instructions given to him/her?
was he/she in the position he/she was?
was he/she using the tools or machine he/she used?
didnt he/she check with his/her supervisor when he/she noted things werent as they should be?
did he/she continue working under the circumstances?
wasnt supervisor there at the time?

Question 5: WHERE
Where did the accident occur?
Where was he/she at the time?
Where was the supervisor at the time?

Where were co-workers at the time?

Where were other people who were involved at the time?
Where were witnesses when accident occurred?

Question 6: HOW
How did he/she get hurt?
How could he/she have avoided it?
How could co-workers have avoided it?
Could supervisor have prevented it? How?