ACCIDENT

INVESTIGATION,
&
LESSONS
LEARNT

OBJECTIVE
To day we shall
Discuss what is an Accident
Study Accident reporting system &
procedure of our Corporation
Learn How to investigate an accident
Lessons learnt from accidents and
How to prevent recurrence

Accident is an
unplanned event
that interrupts the
completion of an
activity & that may
or may not results
in to injury or
property damage.

Accident
As per Factories Act , an accident is
any incident which causes death
Serious injury likely to prove fatal, unconsciousness
Loss of body part(s)
Bodily injury which prevents the injured to absent from duty
more than 48 hrs.
Serious burns
collapse of wall/floor/roof or building forming part of the factory

Accident

As per Petroleum act ,

an accident is any fire or explosion , as a result of ignition of

petroleum or petroleum Vapour attended with loss of human
life or Serious injury or loss of property.

As per Electricity act ,

an accident is any injury or loss of life to human being or
animal due to electrical supply

As per Motor vehicle act

an accident is any injury or death to any person or
damage to any property as a result of motor vehicle
Involvement

Accident
As per Water Act ,
any polluting matter in excess of the prescribed
limit is being discharged or likely to be
discharged in to a stream or well.

As per Air Act ,

Where the emission of any pollutant in to the
atmosphere in excess of the standards laid down
by the state PCB occurs or is apprehended to
occur due to some unforeseen act or event.
As per Environment Act ,
where the discharge of env. pollutant in excess of
the prescribed Stds occurs or is apprehended to
occur due to any unforeseen act or event.

Accidents to be reported as per OISD

1. All fire incidents which has lasted for more than 15
minutes or resulted in shutdown of the unit
2. Any incident involving fatality , in our Premises or the
death of our employee any where on duty.
3. Any incident involving injuries of our employees
resulting in absenteeism from duty for 48 hours or
more
4. Incident involving property loss of more than 5 lacs
5. Blow out or explosion
6. Loss of 500 man-hour or more.
7. Permanent loss of body parts
8. Leakage of Hydrocarbon or Gas from tank/Pipelines
resulting in stoppage of operation.

Reporting of reportable accidents

( LPG / POL Locations)
I.

To be reported by Location in charge immediately

II.

First information report by State Office within 4 hours of the happenings

and then the final report after investigation to

III.

To the concerned Departmental HOD of State.

Factory Inspector/ District Magistrate
Officer in charge of the nearest Police Station
PESO Nagpur
State PCB in case of any violation of pollution rules

GM (Regional Service ),In- charge of S & EP of the Region / HO

Concerned ED / GM In-charge / Principal panelist at HO
Dir (M) in case of accidents involving major injuries , death, fire.
DGM ( C ) / S, H & E dept CO , PESO Dept Nagpur

By Principal panelist, HO to OISD

Reporting of Reportable accidents

(AFS/Regional Admn.Building)
I.

To be reported by Location in charge/Admn. In-charge immediately

II.

First information report by State Office within 4 hours of the happenings

and then the final report after investigation to

III.

to the Departmental Head of the Region

GM (Regional Service ),
In- charge of S & EP of the Region

In- charge of S & EP of the Region / HO

Concerned ED / GM In-charge / Principal panelist at HO
Dir (M) in case of accidents involving major injuries , death, fire.
DGM ( C ) / S, H & E dept CO , PESO Dept Nagpur
Factory Inspector / District Magistrate
Officer in charge of the nearest Police Station
PESO department , Nagpur
State PCB in case of any violation of pollution rules

By Principal panelist, HO to OISD

Reporting of Non Reportable(including near-miss)

accident
i)

To be reported by Location in charge to the concerned Departmental

Head / Head of the State

i)

Final report by State Office after investigation of incident to

a) GM, Regional Services
b) In charge of S&EP of the Region & HO
c) Concerned ED / GM in charge / Principal panelist at HO
d) ED (S,H & E)/CO, New Delhi

iii) By Principal Panelists, HO on quarterly basis to : ED, OISD, New

Delhi

Reporting of Non Reportable (including near- miss)

accident
i)

To be reported by Location in charge to

a) Head of the Department at the Region
b) In charge of S&EP of the Region
c) GM, Regional Services

ii)

Final report by Region after investigation of incident to

a) In charge of S&EP of the Region & HO
b) Concerned ED / GM in charge / Principal panelist at HO
c) ED (S,H & E)/CO, New Delhi

iii) By Principal Panelists, HO on quarterly basis to : ED, OISD, New

Delhi

Accident investigation / Reporting

All final reports of accident must include CARE Analysis
C Cause, A Analysis
R - Remedial measure, E - Expedicious action
All communication to OISD shall only be from principal
panelist from Head Office
The accidents at RO, LPG go down, at customer
premises should be monitors / investigated by respective
departments. If necessary help of S&EP Dept. can be
sought on case to case basis.

First Information Report of Accident

1.
2.
3.
4.

Name of the Location

Site of Accident
Date and Time of Accident
Brief of Events including status at
the time of reporting actions taken,
potential hazards (if any)
5. Probable reason(s) of Accidents
6. No. of casualty (if any)-own employees
- others
7. No.of injured persons- Own employees
- others
8. Extent of damage to Plant/Machinery/
structures / buildings/public property
9. Impact on operations
10. Assistance (if required)

:
:
:
:
:
:

:
:
:
Signature :
Designation:
Date/Time

Reporting of Electrical Accident

All electrical accidents

to be reported
as per section 44 a
of
Indian Electricity
rules 1956

HEINRICH AXIOMS OF IND. SAFETY

1.

THE OCCURRENCE OF AN INJURY INVARIABLY RESULTS

FROM A COMPLETED SEQUENCE OF FACTORS.

2.

THE UNSAFE ACTS OF PERSONS ARE RESPONSIBLE FOR A

MAJORITY OF ACCIDENTS.

3.

THE PERSON WHO SUFFERS A DISABLING INJURY CAUSED

BY AN UNSAFE ACT, IN THE AVG. CASE HAS HAD OVER 300
NARROW ESCAPES.

4.

THE OCCURRENCE OF THE ACCIDENT THAT RESULT IN

INJURY IS LARGELY PREVENTABLE.

5.

THE 4 BASIC MOTIVES FOR OCCURRENCE OF UNSAFE

ACTS PROVIDE A GUIDE TO THE SELECTION OF
APPROPRIATE CORRECTIVE MEASURES.

6.

FOUR BASIC METHODS FOR PREVENTING

ACCIDENTS ARE ENGINEERING REVISION ,
PERSUASION & APPEAL , PERSONNEL ADJUSTMENT
& DISCIPLINE.

7.

METHODS OF MOST VALUE IN ACCDT PREVENTION.

ARE ANALOGOUS WITH THE METHODS REQD. FOR
THE CONTROL OF QUALITY , COST & QUALITY OF
PRODUCTION.

8.

MGT. HAS THE BEST OPPORTUNITY & ABILITY TO

INITIATE THE WORK OF PREVENTION.

9.

SUPERVISOR IS THE KEY MAN IN INDUSTRIAL ACCDT.

PREV.

10.

THE HUMANITARIAN INCENTIVE FOR PREVENTING

ACCIDENTAL INJURY IS SUPPLEMENTED BY TWO
POWERFUL ECONOMIC FACTORS

THE

SAFE

PRODUCTIVELY
INEFFICIENT ;

ESTABLISHMENT

&

IS

THE UNSAFE

EFFICIENT

ESTB.

IS

THE DIRECT
COST OF INDUSTRIAL INJURIES FOR
COMPENSATION CLAIMS &
FOR
THE MEDICAL
TREATMENT IS BUT ONE FIFTH OF THE TOTAL COST
WHICH THE EMPLOYER MUST PAY .

Are Accidents Preventable

Many persons, either through ignorance or

misunderstanding, unfortunately believe
that accidents are the inevitable results of
unchangeable circumstances, fate, or a
matter of luck.
But accidents do not happen without cause
Identification, Isolation, and Control of
these "causes" are the underlying
principles of all accident prevention
techniques.
No person in a supervisory position can be
effective in his job of accident prevention
unless he fully believes that accidents can
be prevented & constantly strives to
achieve this result.

ACCIDENT RATIO ANALYSIS

H.W. HEINRICH (GERMANY)

1931 (Started the Research) 17,53,498 Accidents

FRANK E. BIRD (U.S.A.)

1969 (Proposed the Ratio)

1
29

Major or Lost Time Injury

Minor Injuries
No Injury Accidents

300
Heinrich (1950)

SERIOUS OR DISABLING

10

MINOR INJURIES

30

PROPERTY DAMAGE
ACCIDENTS

600

ACCIDENTS WITH NO VISIBLE

INJURY OR DAMAGE

Bird (1969)

1
3
50
80

Fatal or serious injury

Minor Injuries
First Aid Treatment Injuries
Property Damage Accidents

400
Tye/Pearson (1974/75)

Near Misses (Non Injury/ Damage Accidents)

ELEMENTS WHICH
COULD RESULT INTO
INCIDENTS
1. PEOPLE
2. EQUIPMENT
3. MATERIAL
4.

ENVIRONMEN
T

A large storage tank containing

flammable liquid overflowed in evening
time when it was being filled. The level
indicator and level alarm system of the
tank was defective and the operations
was not monitored. Initially the overflow
was not detected. A security guard
noticed a strong odor and immediately
called the area operations personnel.
Two operators responded by driving a
truck to the area to investigate.

Within minutes, there was a loud

explosion and fire. (It is believed
that their truck provided the ignition
source) It took plant and civic
personnel a day and a half to
extinguish the fires which moved
from one tank to the next. More
than a dozen employees were
hospitalized
and
there
was
significant property damage.

How Did it Start?

The response to alarm raised by

security guard was not prompt as
they did not take him seriously as he
was new on the job.
Like most significant events, a
number of things failed all at the
same time!

What You Can Do

Transfer of product is always a risk with
potentially significant consequences.
Monitor transfers closely so you can detect
and respond to spills and leaks early!!!!
Never drive into a flammable cloud! Vehicles
can provide ignition sourcessuch as a hot
engine manifold or muffler. These are often
well above the auto-ignition temperature of
many flammables. Remember, if a cloud is
ignited by the vehicle you are driving, you
will have a front row seat and be the center
of the explosion.
Take every report of an unusual occurrence
or odor seriously and respond quickly and
thoroughly.

WHY TO CARRY OUT ACCIDENT INVESTIGATION

To find out the cause of accidents &

prevent recurrence
To fulfil any legal requirements
To determine the cost of an accident
To determine compliance with
applicable safety regulations
To process workers claims

THOUSANDS OF ACCIDENT OCCUR

THROUGH OUT THE WORLD EVERY
DAY.

CAUSE(s) OF MOST OF THE

ACCIDENTS ARE:
FAILURE OF PEOPLE
FAILURE OF EQUIPMENT
FAILURE OF SUPPLIES
FAILURE TO BEHAVE OR REACT AS
EXPECTED

ACCIDENT INVESTIGATIONS
DETERMINE HOW & WHY
THESE FAILURES OCCUR.
BY USING THE INFORMATION
GAINED THROUGH AN
INVESTIGATION, A SIMILAR or
PERHAPS MORE DISASTROUS
ACCIDENT COULD BE PREVENTED.

CONDUCT ACCIDENT
INVESTIGATION WITH
ACCIDENT PREVENTION
IN MIND.
INVESTIGATIONS ARE
NOT TO PLACE BLAME

Accidents are usually

complex. It may have 10 or
more event that can be the
causes.
A detail analysis normally
reveal 3 cause levels:
Basic
Indirect
Direct

In spite of their
complexity, most
accidents are
preventable by
eliminating one or
more causes.

OBJECTIVES OF INVESTIGATION
1. Reduce danger to employees and
susceptible public.
2. Prevent company resource losses.
3. Prevent further mishaps.
4. Respond to management needs.
5. Prevent loss of trained personnel.

OBJECTIVES OF INVESTIGATION
6. Develop information.
7. Improve operating efficiency.
8. Define operating errors.
9. Satisfy company rules
10. Reduce work process disruption.
11. Provide protection against litigation.
12.Identify violations of company procedures.
13.Isolate design deficiencies

Investigative Procedures

Actual Procedures used in a

particular investigation
depend on the nature and
results of the accident.

Investigative Procedures
1. Scope of Investigation
2. Selection of investigators. Assignement
of specific task to each
3. Get Preliminary briefing on

Description of accident

Normal Operating Procedure

Maps

Location of Accident Site

List of witnesses

Events that preceded the Accident

Investigative Procedures
4. Visit to Accident Site for updated
information.
5. Inspection of site

Do not Disturb the scene unless a hazard exists

Prepare necessary sketches & Photographs. Keep acurate

record

6. Interview each victim,witness, persons

who were present before & after the
accident.
7. Determine:

What was not normal before the accident

Where the abnormality occurred

When it was first noted

How it occurred

Investigative Procedures
8. Analyse the data obtained as per step-7.
9. Determine

Why the accident occurred

A likely sequence of event & probable causes

(Direct, Indirect,Basic)

Alternative sequence

10. Check each sequence against data from

Step-7

11. Determine the most likely sequence of events

and the most probable causes.
12. Conduct a post-investigation briefing.
13. Prepare a summary report, including the
recommended actions to prevent a recurrence.

Accident Investigation

Accident Investigation
WHO : Who was involved in the accident
Who noticed the accident
Who reported the accident
Who was responsible for Safety
Who was responsible for the accident
Who was called to respond to the accident
WHY:

Why did the accident happen ?

Why safety practices were not applied ?
Why did safety procedures failed to work ?

WHAT : What actually happened ?

What were the losses incurred
What injuries were sustained ?
What could have been done to avoid the
occurrence ?

Accident Investigation
WHERE : Where did the accident occur
Where was the safety officer or Shift in-charge
at the time of accident ?
WHEN : When did the accident occur ?
When were people aware that an accident
occurred
When did help arrive at the sight of accidents ?
HOW : How did the event occur ? (e.g) rapidly, slowly,
without warning etc.
How could safety procedures and practices have
been improved ?
How does the organization learn from the
accidents occurrence ?

Fact Finding
Inspect the accident site before any changes occur
Record pertaining data on maps get copies of all
reports
Collect the documents containing normal operating
procedures reports of any difficulties or abnormalities
Record pre accident conditions , the accident sequence
and post accident conditions
Interview the witness as soon as possible after an
accident
Document the location of victims, witness, machinery,
energy sources and hazardous materials.

Interviews
Get preliminary statement as soon as possible from all
witness
Locate the position of each witness on a master chart
(including the direction of view)
Let each witness speak freely and take notes without
distracting the witness
Record the exact words used by the witness to describe
each observation
Identify the qualification of each witness (name, address,
occupation Years of experience, etc.
Supply each witness with a copy of the statements.

Report of investigation
1. Background information
a) Where and when the accident occur
b) who and what were involved
c) Operating personnel and other witness
2. Account of accident (what happened)
a) Sequence of events
b) Extent of damage
c) Accident type
d) Source of energy & hazardous material
3. Discussions (analysis of accidents how & why)
a) Direct causes (energy sources, hazardous material
b) Indirect causes (unsafe acts and conditions)
c) Basic causes ( Management policies, personal or
environmental factors.)
4. Recommendations to prevent a recurrence (immediate &
long range

An investigation is not
complete until all data are
analysed and a final report is
completed.
In practice, the investigative
work, data analysis and
report preparation proceed
simultaneously.

SAFETY MANAGEMENT
PRINCIPLE 1 :
AN UNSAFE ACT , AN UNSAFE CONDITION & AN
ACCIDENT ARE ALL SYMPTOM OF SOMETHING
WRONG IN THE MGT. SYSTEM.

PRINCIPLE 2 :
WE CAN PREDICT THAT CERTAIN SETS OF
CIRCUMSTANCES WILL PRODUCE SEVERE
INJURIES. THESE CIRCUMSTANCES CAN BE
IDENTIFIED & CONTROLLED.

SAFETY MANAGEMENT
PRINCIPLE 3 :
SAFETY SHOULD BE MANAGED LIKE ANY
OTHER FUNCTION OF COMPANY. MGMT.
SHOULD DIRECT THE SAFETY EFFORTS BY
SETTING ACHIEVABLE GOALS & BY PLANNING,
ORGANISING , COORDINATING , DIRECTING &
CONTROLLING TO ACHIEVE THEM .

PRINCIPLE 4 :
THE KEY TO EFFECTIVE LINE SAFETY
PERFORMANCE IS MGT. PROCEDURES THAT FIX
ACCOUNTABILITY .

PRINCIPLE 5 :

THE FUNCTION OF SAFETY IS TO LOCATE &

DEFINE OPERATIONAL ERRORS THAT ALLOW
ACCIDENT TO OCCUR . THIS CAN BE CARRIED
OUT IN TWO WAYS:
BY SEARCHING FOR ROOT CAUSES OF ACCIDENTS &
BY SEARCHING FOR CERTAIN KNOWN EFFECTIVE
CONTROLS .