What is an accident? An accident can be defined as any occurrence that interrupts or interferes with the orderly progress of the job and usually occurs suddenly and unexpectedly. Some accidents involve human injury, but most do not.

Why should an accident be investigated? The intent of an accident investigation should be to determine what basic condition was responsible for the accident so that proper controls can be provided. Since an accident is a clue that something has gone wrong in the operational process, the same condition(s) responsible for an accident can be causing other related operating losses, i.e. damaged equipment, damaged material, rework, waste, delays dissatisfied customers, etc. Accidents are an operating problem.

Who should investigate? The supervisor or foreman is usually the person in the best position to detect and correct conditions responsible for accidents and losses. The supervisor is directly responsible for getting the most efficient use out of the equipment, material, and people under his control and is the person on whom management relies to solve operational problems.

When should an accident be investigated? An accident should be investigated as soon as practical after the occurrence. Since a supervisor must depend, to a large extent, on the information he obtains from others, the sooner he gets this information the more apt it is to be accurate.

The Investigation -- Since the objective of the investigation is to prevent recurrence of an accident and to eliminate or reduce other related job hindrances, it is important not to jump to the apparent or immediate "cause" of the accident, but to determine the underlying responsible condition. Example: If someone were to slip on a spot of oil, the obvious cause of the accident would be the spot of oil on the floor, however, the real responsible condition would not be determined, or corrected, until it was determined how the oil got on the floor. Correction becomes more than wiping up spots of oil.

To determine responsible conditions, it is necessary to examine the production factors involved in controlling any operation -- Equipment -- Material -- People. Answering the following types of questions concerning the production factors will assist the supervisor in arriving at the proper conclusions and necessary corrective action.

Equipment -- Select

• Why was this equipment used?
• What equipment should be used?
• Was the proper equipment or tool used for the job?

Equipment -- Arrange

• What arrangement problems were present?
• How was the equipment improperly used?
• Was the equipment arranged in such a way as to help rather than hinder?
• Was the work area properly planned for the job?

Equipment -- Use

• What environmental factors contributed to the loss?
• Was the equipment or tool used as intended?
• Was the equipment properly guarded?
• Was the proper Personal Protective Equipment provided and used?

Equipment -- Maintain

• What maintenance problems were evident?
• When should maintenance be performed?
• Was the tool, machine or other equipment defective through use/abuse?

Material -- Select

• Why was this material being used?
• What material should be used?
• What hazards arise from the use of this material?
• Can a less hazardous material be substituted?

Material -- Place

• Is the material being stored in its most advantageous location?
• Is the material readily accessible to the process?
• Where should the material be placed?
• Why was material stored in this location?

Material -- Handle

• How were materials handled?
• Are the proper lifting and/or moving devices being used?
• Are containers well suited for handling?

Material -- Process

• Was material being processed according to plans and specifications?
• How should materials be processed?
• Does process expose workers to injury or illness?

People -- Select

• What qualifications are necessary to perform the task?
• Who is most qualified?
• Why was the employee selected if not most qualified?

People -- Place

• Was the worker placed where his/her talents/abilities were best used?

People -- Train

• Had the worker been fully instructed in the proper way to do the job?
• Were hazards and precautions pointed out?
• What additional training is needed?

People -- Lead

• What instructions or rules were not followed?
• Why were established rules not followed?
• What additional enforcement action should be established?

Instructions for Accident Investigations

1. Begin your investigation as soon as possible after the loss.
2. Go to the scene. Get the big picture first. Consider diagrams or photos.
3. Talk with the injured person if possible -- at the scene of the injury if possible.
4. Talk with other people who know -- witnesses, other employees. Put each person at ease. Investigate to get facts, not to place blame. Make each interview private.
5. Ask questions and repeat the story to be sure that you understand all the circumstances.
6. Ask open-ended, "W" questions -- why, what, why, where, why, when, why, who, how.
7. End each interview on a positive note.
8. Look for all the causes -- deficiencies in equipment, materials, and people.
9. Be careful of reenactments. Don't act for actions to be repeated.
10. Record the facts quickly.
11. Develop your conclusions. Confer with others, solicit prevention ideas.
12. Act positively to prevent recurrence. Correct or refer correction to higher authority.
13. Follow - up to make sure that correction is effective. Publicize for the benefit of all.
14. Look for similar hazards in other situation. Correct/prevent accidents before they occur.