ACCIDENT ESCALATION, INVESTIGATION AND REPORTING:

Why report and investigate accident?

 Learn from what went wrong

 Determine the causes
 Prevent recurrence
 Improve the work environment
 Meet regulatory requirements
 Cost of incidents
 Moral obligation
 Define trends
 Provision of information in case of litigation
 Reduction of operating costs by control of accidental losses
 Expression of concern by management

Definition of terms:

 Accident: an unfortunate event that happens unexpectedly and unintentionally, typically

resulting in damage or injury.
 Incident: an unplanned , undesired event that adversely affects the completion of task
 Near Miss: incident 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
 Lost Time Accident: an accident resulting in time off work

Classification of Incidents for Reporting:

 Near Miss: a near miss incident where there is no loss be it injury or property damage however
it could have resulted in personal harm/ damage under slightly different circumstances, such
incidents are reported to the Supervisor and formally logged on a Near Miss Report.
 Level 1-Minor Incident: a level one incident can typically be dealt with by the person identifying
the problem. The Supervisor should be informed and the incident formally logged on an Incident
Report: this will permit assessment of the incident particularly with regard to the responsibility
of reoccurrence and the potential for a more serious event. (e.g. minor localized fire, minor first
aid injury (less than one day off work))
 Level 2-Serious Incident: immediate action should be taken where possible by the person
identifying the incident. The Supervisor should be immediately informed and should assess the
situation. Thereafter, the emergency plan. (e.g. containable fire, containable environmental
damage, injury (more than one day but less than three days off work)
 Level 3-Severe Incident: immediate action should be taken where possible by the person
identifying the incident. The Supervisor should be informed immediately and assess the
situation. The Supervisor should necessary contact emergency services and emergency
personnel as per the site emergency plan. (e.g. person trapped, serious fire, threat to the safety
 of personnel, serious environmental damage, serious injury (more than 3 days off work),
fatality).

Reporting Incident:

 Employee must report to the supervisor.

 Supervisor are responsible for initiating reporting procedure
 Supervisor is responsible for completion of incident report for near miss, Level 1 and Level 2
incidents involve Safety Manager and Area Safety Representative.
 Supervisor, in conjunction with relevant Department Head is responsible for completion of Level
3 incident reports and also involves Safety Manager and Area Safety Representative.
 Head of Department is responsible for completion of corrected actions.
 Reports to Senior Manager and Safety Manager.

Initial Response: (The Supervisor)

 Takes control of the scene

 Calls first aid and emergency services
 Controls secondary incidents
 Identifies source of evidence
 Preserves evidence from alteration or removal
 Determines the loss potential
 Notifies appropriate management

Incident investigation:

Tips:
 Encourage a no-blame reporting
 Focus must be to improve working conditions and methods
 Approach with an open and objective mind
 All facts learnt corrective action taken
 Fact finding not fault finding
 An opportunity for employees and management to work together to correct an
unacceptable situation
 An incident will happen again if underlying causes are not corrected
 Delve deep to establish underlying causes do not accept all answer given at face value
 Be prepared to look beyond the injured person, his co-workers, supervisor and manager.
 Consider communication skills and language barrier
 Get as much as factual information as possible to get the complete picture

Effective Incident Investigation:

 Establish the facts:

o Who? What? When? Where? How? The size?
 Analyze the facts isolating contributory factors:
o Who or what was involved
o What hazards were present?
 o What controls failed?
 Identify actions to prevent recurrence
 Implement the correct actions

Who would lead the investigations? (The Supervisor):

 They have a personal interest

 They know the people and conditions
 They know how best and where to get the information needed
 They will initiate or take any remedial action
 They benefit from investigating

Collecting evidence and information:

 Record: pre-accident conditions, accident sequence, post-accident conditions

 Position evidence: people (witnesses), equipment, material, environment, use sketches,
maps, and videos. (Consider plant line up, valve alignment, tools labels, and signs).
 People evidence: statements from all involved and witnesses, interview separately.
 Parts evidence: machinery, tools, and other equipment that could have contributed to
the incident.
 Paper evidence: all relevant records such as training records, equipment records,
procedures, code of practices, pre-start checklists, permits, area rules, standards.

Accident Photography:

 Photograph the scene from all sides.

 Use long , medium close-up sequence
 Accompany with good notes and sketches
 Identify by number, time, date and name of photographer
Interviewing witnesses:
 Calm, objective, impartial, open mind, search for facts not opinions
 Do not interrogate/cross examine
 As soon as possible
 Interview separately and privately, use a tape recorder only with witness permission
 In significant conflict ,follows up interviews may be necessary
 Assure them the information is being used for accident prevention not to apportion
blame
 Get the individuals version
 Use open questions (cannot be answered by yes or no)
 Do not express an opinion or argue
 Record critical information quickly
 If not at the site of the accident, use visual aids, sketches, etc
 End on a positive note and keep the line open
 Review completed statement with witness and have it signed

Parts examination:
  Parts: machinery, tool or equipment that could have contributed to the incident
o Proper item for task
o Damage (type, extent, pattern)
o Previous damage (defect, misuse,)
o Wear
o Safeguards(machine guards, emergency cut-off)
o Label, signs, markings

Incident Report:

Typical Content:

 Title, date and time

 Location of the accident
 Type of injury or damage/ who and what was involved
 Cost of losses
 Description of what happened including emergency response sequence
 How the accident occur/ extent of damage
 Direct causes (energy sources, hazard materials etc.), indirect causes (unsafe acts and
conditions), basic causes (personal/ environmental factors)
 Lack of control (management policies)
 Remedial actions (temporary or permanent)
 Management review
 Note:
o Timeliness of report is critical, best reports are written promptly
o Accident reports are usually discoverable .This means they can be used by
parties to an action for damages or criminal charges.

Incident reports are forwarded to the Safety Manager. They are processed as follows:

 All incident reports are analyzed and the summary information is presented at the next
monthly management meeting and safety committee meeting.
 All level 2 and level 3 incidents are reviewed at the next weekly management meeting.
Any lessons learned are communicated to management and employees from
information distributed to all supervisors and on Company Notice Boards
 Incident reports are copied to the relevant Head of Department and General Manager in
the case of Level 2 and Level 3 incident

Near Miss Reporting:

1
Serious injury

10
Minor injury
 30
Property Damage

600
Incidents with no visible injury or damage
Near Miss

ACCIDENT RATIO STUDY

 Near misses provide a much larger base for more effective control of
accident loss
 Eliminate causes of near misses, reduce the potential for more serious
accidents, this is the basis of any proactive safety management system
 High potential incidents should be analyzed thoroughly