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DEFINITIONS
ACCIDENT - The National Safety Council defines an accident as an undesired event that results
in personal injury or property damage.
INCIDENT - An incident is an unplanned, undesired event that adversely affects completion of a
task.
NEAR MISS - Near misses describe incidents where no property was damaged and no personal
injury sustained, but where, given a slight shift in time or position, damage and/or injury easily
could have occurred.
When do you conduct an investigation?
All incidents, whether a near miss or an actual injury-related event, should be investigated. Near
miss reporting and investigation allow you to identify and control hazards before they cause a
more serious incident. Accident/incident investigations are a tool for uncovering hazards that
either were missed earlier or have managed to slip out of the controls planned for them. It is
useful only when done with the aim of discovering every contributing factor to the
accident/incident to "foolproof" the condition and/or activity and prevent future occurrences. In
other words, your objective is to identify root causes, not to primarily set blame.
DEFINITIONS
ACCIDENT - The National Safety Council defines an accident as an undesired event that results
in personal injury or property damage.
INCIDENT - An incident is an unplanned, undesired event that adversely affects completion of a
task.
NEAR MISS - Near misses describe incidents where no property was damaged and no personal
injury sustained, but where, given a slight shift in time or position, damage and/or injury easily
could have occurred.
Who should investigate?
The usual investigator for all incidents is the supervisor in charge of the involved area and/or
activity. Accident investigations represent a good way to involve employees in safety and health.
Employee involvement will not only give you additional expertise and insight, but in the eyes of

the workers, will lend credibility to the results. Employee involvement also benefits the involved
employees by educating them on potential hazards, and the experience usually makes them
believers in the importance of safety, thus strengthening the safety culture of the organization.
The safety department or the person in charge of safety and health should participate in the
investigation or review the investigative findings and recommendations. Many companies use a
team or a subcommittee or the joint employee-management committee to investigate incidents
involving serious injury or extensive property damage.
Training for incident investigation
No one should investigate incidents without appropriate accident investigation training. Many
safety and health consultants and professional organizations provide this type of training. Before
committing resources to training, you might want to check the course contents against the
information found in the National Safety Council's pamphlet, "Accident Investigation ... A New
Approach."
The investigative report should answer six key questions
Six key questions should be answered: who, what, when, where, why, and how. Fact should be
distinguished from opinion, and both should be presented carefully and clearly. The report should
include thorough interviews with everyone with any knowledge of the incident. A good
investigation is likely to reveal several contributing factors, and it probably will recommend
several preventive actions.
You will want to avoid the trap of laying sole blame on the injured employee. Even if injured
workers openly blame themselves for making a mistake or not following prescribed procedures,
the accident investigator must not be satisfied that all contributing causes have been identified.
The error made by the employee may not be even the most important contributing cause. The
employee who has not followed prescribed procedures may have been encouraged directly or
indirectly by a supervisor or production quotas to "cut corners." The prescribed procedures may
not be practical, or even safe, in the eyes of the employee(s). Sometimes where elaborate and
difficult procedures are required, engineering redesign might be a better answer. In such cases,
management errors -- not employee error -- may be the most important contributing causes.
All supervisors and others who investigate incidents should be held accountable for describing
causes carefully and clearly. When reviewing accident investigation reports, the safety
department or in-house safety expert should be on the lookout for catch-phrases, for example,
"Employee did not plan job properly." While such a statement may suggest an underlying
problem with this worker, it is not conducive to identifying all possible causes, preventions, and
controls. Certainly, it is too late to plan a job when the employee is about to do it. Further, it is
unlikely that safe work will always result when each employee is expected to plan procedures

alone.
Implications of accident investigations
Recommended preventive actions should make it very difficult, if not impossible, for the incident
to recur. The investigative report should list all the ways to "foolproof" the condition or activity.
Considerations of cost or engineering should not enter at this stage. The primary purpose of
accident investigations is to prevent future occurrences. Beyond this immediate purpose, the
information obtained through the investigation should be used to update and revise the inventory
of hazards, and/or the program for hazard prevention and control. For example, the Job Safety
Analysis should be revised and employees retrained to the extent that it fully reflects the
recommendations made by an incident report. Implications from the root causes of the accident
need to be analyzed for their impact on all other operations and procedures.

What really causes accidents and incidents?


Author WorkplaceInfo writers 10 Nov 2009
A session at the 2009 Safety Conference, held in Sydney 2729 October 2009, identified the
main causes of injuries and accidents, and discussed ways to reduce their occurrence.
Ever burnt yourself on a barbecue or stove? You werent unaware of the potential hazard, but you
were probably either complacent, not paying attention, in a hurry, tired, or thought you would get
away with it because you had been cooking food for years without harm.
Cristian Sylvestre, principal consultant of Safetrain Pty Ltd, said that accidents and injuries
generally occur because the appropriate controls were not implemented effectively at the time
and, as noted above, ignorance is rarely an issue. After a few repetitions of a task, people tend to
go onto auto-pilot and pay less attention.
Deliberate or unintentional?
Some human errors such as flagrant breaches of OHS policies, procedures or rules are deliberate.
These should be handled via the organisations disciplinary processes. However, this presentation
covered the types of errors that occur unintentionally when a person is in a sub-optimal state for
working.

The most common triggers and errors

Four states or mindsets that people find themselves in will increase their chances of an accident:

rushing to do something

frustration

fatigue

complacency.

Rushing, at about 40% of all cases, was the most common of these.
Those problems cause or contribute to the following critical errors:

eyes not on the task the most common error

mind not on the task

moving into the line of fire

loss of balance, traction or grip.

Those errors in turn increase the risk of injury, and almost all accidents and incidents involve at
least one of them. Many avoidances are purely due to luck (eg If Id been there one second
later/sooner). Sylvestre said that around 80% of people have had more than 20 close calls and
near misses during their lives that could have been fatal.
Other estimates are that 8590% of injuries are self-inflicted, 510% are caused by other people
and only 25% are caused by equipment or events, eg mechanical failures. Note, however, that it
may often be difficult to tell exactly what happened. If a car runs off the road, the driver dies and
the car is wrecked, possible causal factors may include mechanical failure, driver fatigue,
inattention/distraction, excessive speed for the conditions, swerving to avoid an animal or
another vehicle that leaves the scene, etc.
Successful repetition of behaviour leads to habits, which lead to attitudes, which in turn
influences the safety culture. Of the four states that increase risk, complacency is the hardest one
to identify and control.
Note the dominance of human error as a causal factor in the above discussion. Fifty or so years
ago, management or systems failures were the dominant cause of incidents, so much so that
human error tended to be overlooked. But since then, mature OHS systems have been widely
established, so now human error is a far more common cause than systemic failure.

However, many investigations ask questions that will identify and understand the circumstances
that led to human error being made. Furthermore, the people involved are often reluctant to
provide relevant information, in order to protect their own positions, and they will try to attribute
blame to other factors.

Critical error-reduction techniques


Sylvestre outlined a four-step approach towards avoiding the problems described above:
1. Learn to be aware of your state or mindset (or amount of hazardous energy, as Sylvestre
called it), so that you dont make critical errors. For example, identify when you are
rushing and slow down, identify when you are frustrated and calm down before
proceeding. Then you can stop yourself before you make an error.
2. Analyse any close calls, near misses or small errors that occur; it may save you from
bigger ones. Regard them as free lessons.
3. Look for patterns that increase the risk of accidents and injuries. For example, observing
others is the most effective way to identify complacency because it focuses your own
mind to watch the risks that arise.
4. Work on improving your habits.
The aim of this approach is to make individuals responsible for their own safety, but you have to
teach them to think and look for themselves; others cant do it for them. Note again that the
overwhelming majority of incidents are self-inflicted.

http://www.toolboxtopics.com/Gen%20Industry/Seven%20Causes%20for
%20Accidents.htm

SEVEN COMMON ACCIDENT CAUSES


Consider this statistic: 80 out of every 100 accidents are the fault of the person involved in the
incident. Unsafe Acts cause four times as many accidents & injuries as unsafe conditions.
Accidents occur for many reasons. In most industries people tend to look for "things" to blame
when an accident happens, because it's easier than looking for "root causes," such as those listed
below. Consider the underlying accident causes described. Have you been guilty of any of these
attitudes or behaviors? If so, you may have not been injured-but next time you may not be so
lucky.

Taking Shortcuts: Every day we make decisions we hope will make the job faster and
more efficient. But do time savers ever risk your own safety, or that of other crew
members? Short cuts that reduce your safety on the job are not shortcuts, but an increased
chance for injury.

Being Over Confident: Confidence is a good thing. Overconfidence is too much of a good
thing. "It'll never happen to me" is an attitude that can lead to improper procedures, tools,
or methods in your work. Any of these can lead to an injury.

Starting a Task with Incomplete Instructions: To do the job safely and right the first time
you need complete information. Have you ever seen a worker sent to do a job, having
been given only a part of the job's instructions? Don't be shy about asking for
explanations about work procedures and safety precautions. It isn't dumb to ask
questions; it's dumb not to.

Poor Housekeeping: When clients, managers or safety professionals walk through your
work site, housekeeping is an accurate indicator of everyone's attitude about quality,
production and safety. Poor housekeeping creates hazards of all types. A well maintained
area sets a standard for others to follow. Good housekeeping involves both pride and
safety.

Ignoring Safety Procedures: Purposely failing to observe safety procedures can endanger
you and your co-workers. You are being paid to follow the company safety policies-not to
make your own rules. Being "casual" about safety can lead to a casualty!

Mental Distractions from Work: Having a bad day at home and worrying about it at work
is a hazardous combination. Dropping your 'mental' guard can pull your focus away from
safe work procedures. You can also be distracted when you're busy working and a friend
comes by to talk while you are trying to work. Don't become a statistic because you took
your eyes off the machine "just for a minute."

Failure to Pre-Plan the Work: There is a lot of talk today about Job Hazard Analysis.
JHA's are an effective way to figure out the smartest ways to work safely and effectively.
Being hasty in starting a task, or not thinking through the process can put you in harms
way. Instead, Plan Your Work and then Work Your Plan!
"It is better to be careful 100 times than to get killed once." (Mark Twain)

Obstacles and impediments to the safe movement of personnel, vehicles or


machines, such as blocked fire exits.

(b) Forcing pedestrians to walk out onto roadways due to shoulder work
(without the proper safeguards).
(c) Unsafe working and walking surfaces. Holes in the walking or working
surface that an individual can fall throughor get their shoe stuck in. Uneven
floors (greater than inch), cracks inflooring (greater than inch) and uneven
steps

(d) Worn, damaged, or misused tools(cheater bars).


(e) Operation of equipment without the proper protective machine guards.
(f) Working without required protective equipment such as goggles, gloves,
hard hats, adequate footwear or seatbelts.
(g) Worn and/or damaged or unguarded electrical wiring, fixtures and power
cords.
(h) Absence of required signage warning of particular hazards in the area.

Educating and training the workforce in the proper use of equipment


and materials,
awareness of their surroundings, and
understanding their role in the workplace and in
safety will
aid in eliminating these occurrences.
One of the most effective means of preventing accidents/incidents
is eliminating unsafe
conditions through engineering controls,
the second effective means is administrative
controls the
last effective control should be through the use of PPE.