Mr. Christian S.

Sol
Accredited DOLE-OSH Safety
Consultant
Accredited DENR Pollution
Control Officer
 ACCIDENT INVESTIGATION is an analysis,
evaluation & report of an incident, based on
information gathered by the investigator (most
frequently, the SUPERVISOR). The quality &
usefulness of the information is directly related
to the degree of thoroughness & completeness
of the investigation process.

 It is a complete investigation which includes

the objective evaluation of all the facts,
opinions, statements & other related
information, as well as, action steps to
prevent/control recurrence of similar incident.
 To prevent recurrence of similar
accident
 To comply with company policies &
regulatory requirements (DOLE/BWC
– OSHS)
 To improve LOSS CONTROL
MANAGEMENT program/system
 To maintain SAFETY & HEALTH
awareness.
 Swift Investigation is a MUST.
 Understand what you are eliminating: the
root cause/s of the ACCIDENT (near misses,
disabling or non-disabling), now in Loss
Control Management, we call it: DOWN-
GRADING INCIDENT.
1. Gather Information

2. Analyze the Information (Facts)

3. Make Recommendations
(CORRECTIVE ACTIONS)
 1

• Basic Facts
 Who
 What
 Where
 When
 How
• Witness Account
• Physical Conditions
• Existing Records
• Why? why? why?
Look for clues
• Look for conditions that could change
quickly
• Look for unsafe conditions after the incident
• Final condition/positions of
equipment/materials/person
Documentations
• Sketches (neat and legible)
• Photos for precise details
• Mark pictures for references
• Document position of switches/equipment
settings
Existing Records
• Training Records
• Past Accident Reports
• Job Hazard Analysis (JHA)
• Others (service report, orders, permits, etc.)
 2

• Unsafe Acts & Unsafe Conditions

• Standard Operating Procedure (SOP)
• Training/Development of Personnel
• Policies
• Job Hazard Analysis (JHA)
• etc.
 Write down each loss
 Under each loss, write all the contacts with
forms of energy or substance that were
responsible for the loss.
 Under each contact factor, list the substandard
actions & conditions that created it
 Under each substandard action & condition,
list all basic causes which prompted it
 Review of programs, its standards &
compliance with standards
 3

• Simple & clear

• Cost effective

• Compliant to CODES & STANDARDS

 Systematic
 Cause
 Analysis
 Technique
People

Equipment

Material

Environment
• Accidents & other problems are
seldom, if ever, the result of a
single cause.
 LACK
LACKOF
OF BASIC
BASIC IMMEDIATE
IMMEDIATE
CONTROL
CONTROL CAUSES
CAUSES CAUSES
CAUSES INCIDENT
INCIDENT LOSS
LOSS
Inadequate
Inadequate Personal
Personal Substandard
Substandard
Factors Acts/Practices Event Unintended
Unintended
Factors Acts/Practices Event Harm
• •System Harm
System Substandard
• •Standards Substandard
Standards Job/System Conditions Or
Or
Job/System Conditions
• •Compliance Factors
Factors
Compliance Damage
Damage
Description of accident/incident
Evaluation of loss potential

Types of contact or near contact

Immediate/Direct causes

Basic/Underlying causes

System needs
Lack
Lackof
of Basic
Basic Immediate
Immediate
Control
Control Causes
Causes Causes
Causes Incident
Incident Loss
Loss

People
Environment
Property
Process
Lack
Lackof
of Basic
Basic Immediate
Immediate
Control
Control Causes
Causes Causes
Causes Incident
Incident Loss
Loss

Contact with Energy or Substance

Struck against Caught in
Struck by Caught on
Fall to Caught between
Fall on Contact with
Overstress
Lack
Lackof
of Basic
Basic Immediate
Immediate
Control
Control Causes
Causes Causes
Causes Incident
Incident Loss
Loss

Substandard Acts/Practices Substandard Conditions

Failure to warn
Failure to obey rules
Failure to follow procedures
Removing safety devices
Improper lifting
Failure to use PPE
Servicing operating equipment
Horseplay
Inadequate guards / barriers
Inadequate PPE
Defective tools / equipment
Congestion
Inadequate warning system
Disorder
Excessive exposures
Inadequate ventilation
Inadequate illumination
 Lack
Lackof
of Basic
Basic Immediate
Immediate
Control
Control Causes
Causes Causes
Causes Incident
Incident Loss
Loss

Job Factors Personal Factors

Inadequate leadership Inadequate capability
Inadequate engineering Lack of knowledge
Inadequate purchasing Lack of skill
Inadequate tools & Stress
equipment Improper motivation
Inadequate maintenance
Inadequate work standards
Wear & tear
Abuse & misuse
Lack
Lackof
of Basic
Basic Immediate
Immediate
Control
Control Causes
Causes Causes
Causes Incident
Incident Loss
Loss

INADEQUATE
Occupational Health &
1 System
Safety Management
2 Standards System (OSHMS)
3 Compliance
INADEQUATE: Comprehensive Contact w/ Energy or People
Substance above the
1 System (Program) SAFETY threshold limit of the
Environment
Property
2 Standards & HEALTH body or structure Process
3 Compliance PROGRAM
Preventable: 98%
Elements of an Accident Unpreventable: 2%

LACK
LACKOF
OF BASIC
BASIC IMMEDIATE
IMMEDIATE
CONTROL
CONTROL CAUSES
CAUSES CAUSES
CAUSES ACCIDENT LOSS
ACCIDENT LOSS
(Result of
(EVENT)
(EVENT) (Result of
Accident)
1 UNSAFE CONDITIONS 10% Accident)

1 PERSONAL FACTORS H Inadequate guards/barriers

Inadequate PPE
Inadequate capability
Lack of knowledge A Defective tools/equipment
Congestion
BUSINESS
Lack of skill
Stress Z Inadequate warning system
Disorder
Profitability
Growth
Improper motivation
A Excessive exposures
Inadequate ventilation Continuity
2 JOB FACTORS
Inadequate leadership R Inadequate illumination

Inadequate engineering
Inadequate purchasing D 2 UNSAFE ACTS 90%
Failure to warn
Inadequate maintenance
Inadequate tools & equipment S Failure to obey rules
Failure to follow procedures
Wear & tear
Removing safety devices
Inadequate work standards Why you
Improper lifting
Abuse & misuse
Failure to use PPE need
Servicing operating equipment SAFETY !!!
LOSS CAUSATION MODEL Horseplay
1 Hazard Elimination
2 Product/Process Substitution
3 Engineering Control
4 Administrative Control
5 Personal Protective Equipment (PPE)
 ACCIDENT INVESTIGATION
(General Process Flow)

Ensure Gather
immediate facts
Secure
medical about the
the area
treatment accident:
of the witnesses
Injured

Identify Document
the root the facts:
Follow- Corrective
cause hard
up action
(causal evidence,
factors) witness
1. A SUMMARY OF INFORMATION
(indicated in the AI report form)
2. An ANALYSIS OF INFORMATION
3. RECOMMENDATION/S (CORRECTIVE
ACTION/S)
And, ensuring that the
recommendations ARE
IMPLEMENTED/COMPLETED by all
concerned.
 LEADERSHIP & MANAGEMENT PLANNED JOB/TASK JOB/TASK
ADMINISTRATION TRAINING INSPECTION ANALYSIS OBSERVATION
& PROCEDURES

PERSONAL ORGANIZATIONAL HIRING & ACCIDENT & ACCIDENT &

COMMUNICATION RULES PLACEMENT INCIDENT INCIDENT
INVESTIGATION ANALYSIS

PURCHASING & EMPLOYEE HEALTH CONTROL PERSONAL MEASUREMENT

ENGINEERING TRAINING & SERVICES PROTECTIVE AUDIT SYSTEM
CONTROLS EQUIPMENT

GROUP GENERAL EMERGENCY RECORDS & OFF-THE-JOB

MEETINGS PROMOTIONS PREPAREDNESS REPORTS SAFETY
A. Setting of PRIORITIES – essence of
planning is in setting priorities, this
view reflects the resource limitations
of the company.
B. Developing OBJECTIVES, TARGETS –
use SMART-approach criteria.
C. Designing Evaluation & Monitoring
TOOLS for the OSH Program.
D. Preparing SPECIFIC OBJECTIVES
(activities/action steps) to implement
key performance areas of ACCIDENT
INVESTIGATION Program.
 The SAFETY & HEALTH PROGRAM should be built
around the basic PROGRAM ELEMENTS & must
conform to C.I.M. (CONTINUOUS IMPROVEMENT
MODEL) outlining the details, such as, targets,
monitoring systems, awards, appraisal factors, etc.
NOTE: Developing the OSH PROGRAM is
COOPERATIVE EFFORTS by all concerned. The
preparation of the OSH PROGRAM is timed during
the BUDGET PREPARATION.
The SPECIFIC OBJECTIVES or
ACTIVITIES/ACTION STEPS should
conform to the following SMART–
approach criteria:
(S) SPECIFIC or SIMPLE
(M) MEASURABLE
(A) ATTAINABLE
(R) RELEVANT or
REALISTIC
(T) TIME BOUNDED
To have an effective program on
ACCIDENT INVESTIGATION within the
year 2014 that covers the following KEY
PERFORMANCE AREAS (requirements or
standards):
A Accident Investigation Procedure
B Scope of Accident Investigation
C Remedial Follow-up and Action
D Senior Management Participation
E Evaluation of Program Effectiveness
 Program Element Key Performance Areas Specific Objectives Person’s Support Time Status
Objectives (Requirements or Standards) Activities/ Action Steps Responsible Needed Frame
To have an effective A. Accident Investigation
program on Procedure & Training
ACCIDENT Program
INVESTIGATION B. Scope of Accident
within the year 2014 Investigation
that covers the key
performance areas C. Remedial Follow-up and
(requirements or Action
standards). D. Senior Management
Participation
E. Evaluation of Program
Effectiveness
 Program Element Key Performance Areas Specific Objectives Person’s Support Time
Objectives (Requirements or Standards) Activities/Action Steps Responsible Needed Frame
To have an effective A. Accident Investigation A. To have procedures & training H&SC Top Jan 1
program on Procedure & Training module on Accident Mgrs & MGNT – Jun
ACCIDENT Program Investigation by 1st qtr. Supvrs 30
INVESTIGATION 1. To have an accident
within the year 2014 HR Mgr
investigation procedure &
that covers the key report forms for personal Safety
performance areas injury/illness & property Officer
(requirements or damage by Jan 31. Health
standards).
2. To have a training module by Officer
Feb 28.
3. To have disseminated
procedures in reporting
accidents by Mar 31.
 Program Element Key Performance Areas Specific Objectives Person’s Support Time
Objectives (Requirements or Standards) Activities/Action Steps Responsible Needed Frame
To have an effective 4. To have conducted 2-day H&SC Top MGNT Jan 1
program on training on accident Mgrs & Budget of – Mar
ACCIDENT investigation for all mgrs & Supvrs P60T/run 31
INVESTIGATION supvrs by 2nd qtr. (meals,
within the year 2014 HR Mgr
B. Scope of Accident B. To have developed the materials &
that covers the key scope of accident Safety trainer’s fee)
Investigation
performance areas investigation, including its Officer
(requirements or proper dissemination by 1st Health
standards). qtr. Officer
C. Remedial Follow-up and C. To have standards needed
Action to ensure implementation of
remedial follow-up &
corrective action/s by 1st qtr.
 Program Element Key Performance Areas Specific Objectives Person’s Support Time
Objectives (Requirements or Standards) Activities/Action Steps Responsible Needed Frame
To have an effective D. Senior Management D. To have ensure H&SC Top MGNT Jan 1
program on Participation implementation of the Mgrs & – Dec
ACCIDENT following activities starting Supvrs 31
INVESTIGATION Jan 2014.
within the year 2014 HR Manager
1. Monitor status of accident
that covers the key prevention program. Safety
performance areas Officer
(requirements or 2. Implement WTGT.
Health
standards). E. Evaluation of Program E. To have performed annual Officer
Effectiveness evaluation & review of
program effectiveness by
end of Dec.
 Program Element Key Performance Areas Program Standards STATUS
Objective/s (Requirements or Standards) Set or Established by the Organization Achieved or Not
Achieved
To have an effective A. Accident Investigation A. Accident/Incident investigation
program on Accident Procedure & Training procedure/form shall be
Investigation within the Program developed/established. Its dissemination &
year 2014 that covers required 2-day training to all supervisors
the following key shall be completed without delay.
performance areas B. The scope of accident investigation shall
(requirements or B. Scope of Accident cover both disabling & non-disabling injury
standards) Investigation accidents, property damage and process
delay.
C. Remedial follow-up shall be monitored by
C. Remedial Follow-up and the H&S Committee to ensure corrective
Action action/s are implemented without delay.
Program Element Key Performance Areas Program Standards Set or Established by the STATUS
Objective/s (Requirements or Standards) Organization Achieved or Not
Achieved
To have an D. Senior Management D. Senior managers shall ensure that
effective program Participation accident/incident prevention are carried out
on Accident in their respective area of responsibility.
Investigation within E. The accident/incident investigation program
the year 2014 that E. Evaluation of Program element shall be evaluated annually by the
covers the following Effectiveness Health & Safety Committee to determine its
key performance effectiveness.
areas
(requirements or
standards)