2.

Accident Investigation and Analysis

Proper procedures, Types of accidents and

Analysis, Investigation Process, Identification
and Classification of Important factors,
Sensory Illusion, Hazard analysis techniques
and Methods of accident cost estimation.

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Questions
Identify the potential hazards in the workplace.
What is the difference between Safety and
Health?
What is the difference between hazards and
risks?
What are the costs of accidents?

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Table 1: Employment Patterns in Malaysia

Type of Sector
Manufacturing
Community
social and personal
service
Wholesale, retail trade,
hotel & restaurant
Agricultural, forestry
& fishing
Other sectors
Construction
Total

Person (000)
1907.8

Labor Force%)
22.2

1787.5

20.7

1616.0

18.8

1616.5
925.9
745.9
8599.6

18.8
10.8
8.7
100

Source: Department of Statistics, Malaysia, 2001.

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WHAT ARE THE POTENTIAL HAZARDS IN

THE WORKPLACE
1. Slips, trips and falls
2. Asbestos
It is often found in roofs and exterior walls, boilers, vessels and pipework, ceilings,
interior walls and panels, flooring materials, air handling systems, domestic appliances,
brake/clutch linings, fire blankets, etc
3. Hazardous substances
These can include chemicals that people make or work with directly, and also dust, fume
and bacteria which can be present in the workplace. Exposure can happen by breathing
them in, contact with the skin, plashing them into the eyes or swallowing them. If
exposure is not prevented or properly controlled, it can cause serious illness, including
cancer, asthma and dermatitis, and sometimes even death.

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4. Working at height
5. Musculoskeletal disorders
6. Using computers or other display screen equipment
7. Noise
8. Vibration
9. Electricity
10.Work Equipment and Machinery
11. Maintenance and building work
12.What are the risks from transport in your workplace
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13. Pressure systems

14. Fire and explosion
15. Radiation
16. Stress

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OCCUPATIONAL SAFETY AND

HEALTH
part 2

Accident Investigation and Analysis

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Definition of accident

Any unplanned event that causes injury, illness,

property damage or harmful disruption of work
process.
Dan Hartshorn

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Why is the accident investigation important?

When an accident occurs, it is important that it be
investigated thoroughly, the results of a
comprehensive accident report can help safety and
health professionals pinpoint the cause of the
accident.
This information can be used to prevent future
accidents, which is the primary purpose of accident
investigation.

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What is the reason for investigating an

accident?
The primary reason for investigating an accident is
not to identify a scapegoat, but to determine the
cause of the accident.

The investigation concentrates on gathering factual

information about the details that led to the accident.
If investigations are conducted properly, there is the
added benefit of uncovering problems that did not
directly lead to the accident.

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Reasons for investigating an accident

This information benefits the ongoing effort of reducing

the likelihood of accident.
As problems are revealed during the investigation,
action items and improvements that can prevent
similar accidents from happening in the future will be
easier to identify than at any time.
(Society of Manufacturing Engineers)

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Types of accident investigations

There are two types of accident
investigation:
Accident report
Accident analysis report

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An accident report is completed when..

When the accident in question represents only a
minor incident, It answers the following questions:
Who, what , where, when and how, but it does not
answer the why question.

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Who writes the accident report?

An accident report can be completed by a person
with very little formal investigation and reporting
training or experience.
Supervisors often complete accident report which, in
turn, might be used later as part one of a more indepth accident report.

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When is an accident analysis report completed?

When the accident in question is serious, The level of

report should answer the same questions as the
regular accident report plus one more-why.

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Reasons for the analysis

The analysis is undertaken for the purpose of
determining the root cause of the accident. Accident
analysis requires special skills and should be
undertaken only by an individual with those skills.

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Reasons for the analysis

1.

The accident analysis must identify the actual root cause

or the company will spend resources treating only
symptoms or even worse, solving the wrong problem.
2. Serious accidents are always accompanied by the
potential for litigation. If there might be legal action as a
result of an accident, it is important to have a
professional conduct the investigation even if it means
bringing in an outside consultant.

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An accident report is required when..

The accident is a minor incident that did not
result in :
1. Death,
2. Loss of consciousness,
3. Professional medical treatment beyond first aid,
4. More than one additional day of lost work beyond
the day of the accident,
5. Any kind of modifications to the employee's work
duties beyond those that might occur on the day of
the accident.

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What is the First action after an

accident?
The first thing to do when an accident takes place is
to implement emergency procedures. This involves
bringing the situation under control and caring for the
injured worker.
As soon as all emergency procedure have been
accomplished, the accident investigation should
begin. Waiting too long to complete an investigation
can harm the result.

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Why is it important to conduct investigations

immediately?
First, immediate investigations are more likely
to produce accurate information.
Second, it is important to collect information
before the accident scene is changed and
before witnesses begin comparing notes.
Human nature encourages people to change
their stories to agree with those of other
witnesses.

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The purpose of investigation

The purpose of an accident investigation is to collect
facts.
It is not to find fault. It is important that safety and
health professionals make this distinction known to all
involved. Fault finding can cause reticence among
witnesses who have valuable information to share.
Causes of the accident should be the primary focus.
The investigation should be guided by the words of
who, what, when, where, why and how.

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The purpose of investigation

Questions to ask when interviewing witnesses

Questions to help the investigator

1.
2.

What type of work was/were the injured person(s )

doing?
Exactly what was the injured persons doing or trying to do
at time of the accident?
3.

4.

Was the injured person proficient in the task being

performed at the time of the accident?

Was the injured person authorized to use the equipment or

perform the process involved in the accident?
5.

Were there other workers present at the time of the

accident?

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Questions.
6.

Was the task in question performed according to

approved procedures?

7.

Was proper equipment being used, including

personal protective equipment?

8.

Was the injured employee new to the job?

9.

Was the process, equipment, or system involved

new?

10. Was the injured person being supervised at the time

of the accident?
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Questions..
11. Are there any established safety rules or procedures
that were clearly not being followed?
12. Where did the accident take place?
13. What was the condition of the accident
site at the time on the accident?
14. Has a similar accident occurred before? If so, were
corrective measures recommended? Were they
implemented?
15. Are there obvious solutions that would
have prevented the accident?
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Who should conduct the accident investigation?

Responsible supervisor?
The safety and health professional?
A higher-level manager?
An outside specialist?
Investigative team?

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What are the reasons for various approaches?

Factors considered:

Size of the company

Structure of the companys safety and health program
Type of accident
Seriousness of the accident
Technical complexity
Number of times that similar accidents have occurred
Companys management philosophy
Companys commitment to safety and health

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The steps of investigation

Isolate the accident scene

Record all evidence
Photograph or videotape the scene
Identify witnesses
Interview witnesses

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OCCUPATIONAL SAFETY AND HEALTH

Cause & Effect diagram (group discussion)

Management

Man

Material

Why do accidents
Happen?

Environment

Method

Machine

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Group discussion

Design a form to record work related injuries so that

all relevant information is captured and further
action and preventive measures can be taken

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1. Isolate Accident scene

Maintain as closely as possible the conditions that existed at the
time of the accident.

Block off the entire area by barriers or heavy yellow tape.

Keep curious on lookers from removing, disturbing, or

unknowingly an destroying vital evidence.

Remove the injured worker as soon as emergency procedures

are being completed.

Keep the scene until all pertinent evidence has been collected
or observed and recorded.

Put a security guard in the accident scene, if necessary.

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2. Recording the evidence

Make a permanent record of all pertinent evidence:
Certain types of evidence may be perishable.
The longer it must be isolated, the more likely the
evidence will be disturbed, knowingly or unknowingly.
A critical piece of equipment on a critical component
in a larger process, pressure to get it back in
operation.

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To record the evidence

Evidence can be recorded by:

Written notes
Sketches
Photography
Videotape
Dictated observations
Diagrams

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3. Photograph or videotape scene

Safety and health professional should be
proficient the operation of a camera.
Camera should be on hand, loaded, and ready
to use.
Place a ruler or coin next to the object when
making a close up photograph to help
demonstrate the objects size or perspective.

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4. Identify witnesses
Compile a witness list.
- List in three categories :
i. Primary witnesses are eye witnesses to the
accident.
ii. Secondary witnesses - did not actually see the
accident happen, but were in the vicinity and arrived
on the scene very shortly after the accident.
iii. Tertiary witnesses are witnesses who were not
present at the time of the accident nor afterward but
may still have relevant evidence to present

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How to interview witness

Interview All witnesses
Primary witnesses, followed by secondary and last
tertiary .
Techniques used should lead to objective, accurate
and untainted information.
Begin as soon as possible after compiling the list
Best place to interview is at the accident scene,
otherwise, elsewhere.
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Interview witness
Removed all distractions, no interruptions and the
witness is alone.
All persons interviewed should be allowed to relate their
recollection without fear of contradiction by other
witnesses.
Select a neutral location in which witnesses will feel
comfortable.
Avoid the principal's office syndrome, by selecting a
location that is not likely to be intimidation to witnesses
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Important actions on interview witness

Put the witness at ease and listen.
Listen to what is said, how it is said, and what is not
said.
Ask question with open-ended format.
Do not ask did you see the victim pull the red
level? ask tell me what you saw?

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Reporting accidents
An accident investigation should culminate in a
comprehensive accident report.
The purpose of the report is to record the findings of
the accident investigation, the cause or causes of the
accident, and recommendations for corrective action.
If an accident results in the death of an employee or
hospitalization of five or more employees, a report
must be submitted to the nearest OSHA office within
48 hours. This rule applies regardless of the size of
the company.

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Reporting accidents
Accident report forms vary from company to company.
However, the information contained in them is fairly
standard.
Regardless of the type of form used, an accident
report should contain at least the information needed
to meet the record-keeping requirements set forth by
OSHA.
According to the National Safety Council this
information includes at least the following:
Case number of the accident
Victims department or unit
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Reporting accidents
Location and date of the accident or date that an
illness was first diagnosed.
Victims name, social security number, gender, age,
home address, and telephone number
Victims normal job assignment and length of
employment with the company
Victims employment status at the time of the accident
( temporary, permanent, full-time, part-time)
Case numbers and names of others injured in the
accident

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Reporting accidents
Type of injury and body part (s) injured (e.g., burn to
right hand; broken bone, lower right leg) and severity
of injury (i.e., fatal, first aid only required,
hospitalization required)
Name, address, and telephone number of the
physician called
Name, address, and telephone number of the hospital
to which the victim was taken
Phase of the victims work day when the accident
occurred (e.g., beginning of shift, during break, end of
shift, and so on)
Description of the accident and how it took place,
including step be step sequence of event leading up
to the accident
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Reporting accidents
Specific tasks and activities with which the victim was
involved at the time of the accident
Employees posture or proximity related to his or her
surroundings at the time of the accident (standing on a
ladder,)
Supervision status at the time of the accident
(unsupervised, directly supervised, indirectly
supervised)
Causes of the accident
Corrective actions that have been taken so far
Recommendations for additional corrective action

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Ten accident investigation mistakes

1. Failing to investigate near misses.
A near miss is simply an accident that did not happen
because of luck.
Investigating near misses can reveal critical accident
prevention information.

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Ten accident investigation mistakes

2.Taking ineffective corrective action.
Ineffective corrective action is often the result of a
cursory accident investigation.
Should look for the root cause, not the symptoms.
Corrective action based on symptoms will not prevent
future accidents.

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Ten accident investigation mistakes

3.Allowing your biases to color the results of
the investigation.
Look for facts and be objective when investigating

an accident.
Do not make assumptions or jump to conclusions.

Eliminate bias in accident investigations - use a

standard, structured routine and to skip no steps in
the routine.

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Ten accident investigation mistakes

4. Failing to investigate in a timely manner.
- investigations should begin as soon as possible after
the accident.
- evidence will be lost, corrupted, or compromised.
- influenced by the opinions of their fellow workers and
witnesses.
People walking through an accident scene can
compromise the integrity of the scene by unwittingly
destroying evidence.

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Ten accident investigation mistakes

5. Failing to account for human nature when conducting
interviews.
Those involved in an accident as well as witnesses to an
accident will say during an interview will be shaped by their
desire to escape blame, deflect blame to someone else, or
protect a friend.

It is important to interview witnesses and others involved privately

and individually, and to look for corroborating evidence to
support (or refute) their input.

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Ten accident investigation mistakes

6. Failing to learn investigation techniques.
Safety and health professionals should complete
specialized training or undertake self-study to learn
investigation techniques.
An unskilled investigator is not likely to conduct a valid
investigation.

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Ten accident investigation mistakes

7. Allowing politics to enter into an investigation.
The goal of an investigation is and must be to identify
the root cause so that appropriate corrective action
can be taken.
Personal likes, dislikes, favoritism, and office politics
will corrupt an investigation from the outset.

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Ten accident investigation mistakes

8. Failing to conduct an in-depth investigation.
- in a hurry
- pressure from higher management to get this thing behind us.
- can lead to a rushed investigation
- the goal is to get it over with,
- not to find the root cause of the accident.
Surface-level investigations almost ensure that the same type of
accident will happen again.

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Ten accident investigation mistakes

9. Allowing conflicting goals to enter into an
investigation.
The ultimate goal of an accident investigation is to
prevent future accidents and injuries.
Some may see the investigation as:
- an opportunity to deflect blame,
- others may see it as an opportunity to protect the
organization from litigation,
- to explain not meeting production quotas or
performance standards.

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Ten accident investigation mistakes

10. Failing to account for the effects of uncooperative
people.
- People will not always cooperate for a variety of
reasons, all growing out of the concept of received
self-interest.
Safety and health professionals need to understand
that self-interest is one of the most powerful
motivators of human beings and factor this into their
planning for accident investigations.

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Figure 2.3 OSHA Form 300: Log of Work-Related Injuries and Illnesses. (This form is available in larger format on
the Companion Website.)

Safety and Health Economics

Need to formulate prevention of employee injuries and illnesses into
economic objectives not merely humanitarian aspirations
Prevention of employee injuries and illnesses can be formulated as
an economic objective : more meaningful to management than
mere humanitarian aspirations

Accidents, injuries and illnesses have undeniable costs that

contribute nothing to the value of products manufactured by the firm
or services performed

Annual cost of injuries and illnesses in many industries dwarfs the

total profit picture but many of these costs are subtle and difficult to
estimate.

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Case study
A metal products fabrication and assembly plant employs 250 workers
and has the following injury-illness experience for the year (workers
are employed on a regular 40-hr-workweek basis)
File 1 January 31: Press-blanking operator lacerates hand on strip
stock scrap from punch press; first aid received no medical
treatment ;worker remains on the job
File 2 February 19:Maintenance worker, not wearing eye protection,
operating grinding machine in tool room, incurs eye injury from flying
chip; medical treatment required; injury occurs on Tuesday , employee
returns to regular job at regular time on Thursday
File 3 February 27: Assembly worker becomes ill owing to noxious
odour from remodelling operation in the assembly area; receive
permission from supervisor to take the rest of the day off; does not go
to a doctor or clinic; reports to regular work on time the next day

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File 4 March 2: Sewing machine operators right finger pulled into

unguarded drive belt pulley on sewing machine; small fractured
revealed by X ray; splint applied; worker returns to regular work at
regular time the next day.
File 5 March 19: Dockworker sprains ankle on loading dock; moved to
office job for two workweeks.
File 6 May 2: Maintenance worker entangles finger in rope as winch is
released; taken to clinic for X ray; no fractures found; no treatment;
worker returns to regular work the next day.
File 7 June 7: Yard worker exposed to poison ivy while clearing weeds
in tank farm area behind plant; rash develops; treated with prednisone
adrenocortical steroid drug precribed; no time lost
File 6 July 6: Assembly worker loses two workdays recuperating from
severe allergic reaction to wasp stings incurred while cleaning his attic
at home; medical treatment with prescription drugs
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 File 9 August 4: Maintenance worker ungrounded portable electric drill to

repair equipment in assembly area is electrocuted. Date of death: August 4
File 10 August 7: Loaded pallet in loading dock area falls from forklift on
dock workers left foot; worker was not wearing steel-toed shoes; worker
examined on hospital emergency room and X ray revealed no fractures or
other injuries; worker receives whirlpool therapy and goes home; worker
reports back to his regular job on time next day and wears his companyissued safety shoes.
File 11 August 9: Maintenance worker in the tool room incurs injury from
foerign object in the eye; irrigation method to remove foreign object, which
was not embedded in the eye; worker returns to regular job.
File 12 September 11; Worker in final assembly diagnosed with carpal
tunnel syndrome from repetitive work; surgery prescribed; worker misses 3
weeks of work before returning to regular job with engineering
improvements to the worlstation.

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Classification of cost of accident

Insured costs
Uninsured costs

Insured costs of accidents is a simple

matter of examining accounting records.

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Classification of cost of accident

Which are the uninsured cost?

Class 1: Lost workdays, permanent partial disabilities and

temporary total disabilities.

Class 2: Treatment by a physician outside the companys

facility.
Class 3: Locally provided first aid, property damage of less than
$100 or the loss of fewer than eight hours of work time.

Class 4: Injuries that are so minor they do not require the

attention of a physician, result in property damage of
$100 or more, or cause eight or more work hours to be
lost.
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Classification of cost of accident

Average uninsured costs for each class of
accident can be determined by pulling the
records of all accidents that occurred
during a specified period and sorting the
records according to class.
Some accident costs that might be
overlooked:

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Other cost estimation Methods

Lost work hours

Medical costs
Insurance premiums and administration
Property damage
Fire losses
Indirect costs

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Classification of cost of accident

Checklist for
Estimating the hidden costs of accident
paid time to the injured employee on the day of the
accident.
Paid time of any emergency-responder personnel involved
(including ambulance driver).
Paid time of all employees who were interviewed as part of
the accident investigation.
Paid time of the safety personnel who conducted the
accident investigation.
Paid time of the supervisor involved in the accident
investigation and accident response.
Paid time to employees near the accident working.
Paid time to employees who spent time talking about the
accident as news of it spread through the cos grapevine.

High cost of Pain

When employees are in pain, they respond by
taking sick leave from work. Sick leave due
to unspecified pain costs employers more
than $3 billion in lost workdays.
Approximately 17 million employees in the
USA take an average of three days of sick
leave per year to deal with unspecified pain
(e.g., headaches, neck pain, back pain, and
menstrual pain).
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Hidden costs
1. Cost of wages paid for time lost by workers
who were not injured
2. Cost of damage to material or equipment
3. Cost of wages paid for time lost by the
injured worker
4. Extra cost of overtime work necessitated by
the accident
5. Cost of wages paid supervisors for time
required for activities necessitated by the
accident
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Cont..
6. Wage cost by decreased output of injured worker and
return to work
7. Cost of learning period of new worker
8. Uninsured medical cost borne by the company
9. Cost of time spent by higher supervision and clerical
workers on investigation or in the processing of
compensation application forms
10.Miscellaneous usual cost public liability claim cost,
cost of renting equipment, loss of profit on contracts
canceled or order losses..

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Figure 2.8 Direct costs of accidents (workers compensation premiums and medical insurance) represent only the tip
of the iceberg.

Recordkeeping
- important
- to observe trends
1.Traditional indexes statistical measures used :
frequency measures the number of cases per
standard quantity of workhours
severity measures the total impact of these cases
in terms of lost workdays per standard quantity
hours
seriousness ratio of severity to frequency
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2.Incidence rates
total injury illness incident rate =
# of injuries and illnesses including fatalities X 200,000
total hours worked by all employees
during the period covered
200,000 is based on the number of hours a full-time worker
typically work is ~ 50 weeks per year at 40 hours per week (40 x
50 = 2000) x 100 workers = 200000 hrs/yr

The total injury-illness rate represents the number of

injuries by a 100- employee firm in a full year

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The total injury-illness incidence rate includes :

i. Injury incidence rate

ii. Illness incidence rate
iii.Fatality incidence rate
iv.Lost-workday-cases incidence rate (LWDI)
v. Number of-lost-workdays rate
vi.Specific-hazard incidence rate

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LWDI

Lost Workday-cases incidence rate (LWDI),

does not include the date of injury or the onset of illness, use
calendar days not workdays
- LWDI most recognized, consider only injury not illnesses and
fatalities
- one or more work days lost or days in which the worker is
transferred to another job
- consider only injuries
- based on clear evidence-more precise and robust measure of firms
overall effectiveness of

s & H programs

- only consider lost-time injuries-where restricted work activity

cases are considered as lost-time cases
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RECORDKEEPING FORMS
Standardized formats to keep records of injury and illness
a. Log of work-Related Injuries and illnesses- Basic Form OSHAs
Form 300
b. Summary of Work-Related Injuries and illnesses OSHAs Form
300A
- to be displayed and posted in a prominent place so that
employees can see what injuries and illnesses have been
recorded for the year
- employers responsibility to enter data correctly into the log
and summary
- General records are required to be saved for a period of 5 years
- person completing the form must be able to distinguish
between occupational injuries and illnesses.
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 Occupational injuries : lacerations, fractures,

sprains, and amputations that are the result of a
work accident or an exposure involving a single
incident in the work environment (including animal
bites, chemical exposure)
Illnesses : any abnormal condition or disorder not
classified as an injury and caused by exposure to
environmental factors associated with employment
c. Injury and Illness Report (OSHAs Form 301)- Each page
of the report corresponds to a single line entry in the log

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Case Study :

A worker was struck in the head and killed by the sudden movement
of a large wrench used or releasing gates on the bottom of railroad
hopper cars. The worker used a powerful, 3-to-4-foot long wrench to
trip a mechanical latch on the bottom gate of the car. The wrench was
supposed to be of a ratchet type, so that when the gate was tripped, the
tremendous weight of the bulk of material in the hopper car would not
suddenly force the wrench back on the worker. But for some reason
the ratchet wrench was not available, and workers had been using an
ordinary rigid wrench to release the latch. Only a week before the
fatality occurred, another worker had narrowly escaped the same
injury when he lost control of the same wrench in the same operation.

How would you go about investigating the accident? What is the

root cause?
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Class exercise 2.28

Top management has set a safety and health objective

for the year for a plant employing 135 employees.
The objective is to reduce LWDI of the firm to a level
lower than the national average: 3.6. By May 1, the
safety and health manager has logged 12 first aid
cases, 3 lost time injuries, and 2 illnesses, both of
which resulted in hospitalization. Based on these
preliminary results, does it appear that the firm will
meet top managements objective for the year?
Show calculations to justify your conclusion.

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Figure 2.9 OSHA Form 300 for Exercises 2.30 and 2.33. (This form is available in larger format on the Companion
Website.)

Class exercise 2.30

On February 1, a 50-employee firm posts its annual

OSHA log as shown in figure 2.9. Complete the
table and calculate the following:
1. Total injury incidence rate
2. Total illness incidence rate
3. Number-of-lost-workdays rates
4. LWDI

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