An accident is an unplanned and unwelcome event which disrupts normal routine.

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1 ACCIDENT INVESTIGATION What is an Accident? An accident is an unplanned and unwelcome event which disrupts normal routine. Accidents can result in: Death, injury, illness or a near miss Damage to equipment or property Disruption of work Legal costs What is a Near Miss? A near-miss is an accident that could have caused an injury but didn t - for example, a hammer gets dropped by a person working off a ladder but misses the person footing the ladder and hits the floor, no damage or injury; the hammer hits the floor bounces and smashes a window, damage; the hammer hits the person footing the ladder on the head, injury (minor, serious or fatal). It is often chance that decides whether the outcome of an accident is an injury or a near miss. So serious near-misses should be taken as a warning and also be reported and investigated. Why investigate accidents? Prevent similar accidents occurring in the future Revise and improve risk assessments, procedures and safety arrangements Enhance working environment and layout Increase safety awareness The aim of accident investigation should be: to prevent a recurrence of the same accident and NOT to assign blame to individuals. safetyunit@gre.ac.uk May 2012 Page 1 of 5

2 Causes of Accidents Accidents seldom have only one simple cause. Usually they occur because of a combination of factors (Unsafe Conditions and Acts) such as: environmental eg noise, fumes, poor lighting, slippery floor surfaces design eg cramped work area, illogical workplace layout, unsuitable tools or equipment systems and procedures eg instructions not updated to reflect work changes, maintenance not carried out human behaviour eg rushing to get a job done, helping a colleague with an unfamiliar task, not following procedures When you are investigating an accident, to find the cause(s) of it, all contributory factors should be identified. If you are not familiar with the area or the work, enlist the help of local managers and supervisors and other individuals doing similar work. Strategy for Investigation Collect Facts and Evidence Visit the accident site as soon as possible. After serious accidents, isolate the accident site and try to ensure that equipment and materials are not removed or interfered with unless this in itself is a danger to others. You may need to record where people and items were at the time of the accident. Diagrams or sketches of the accident site can be very useful in investigations, as can photographs if it is possible to arrange them quickly. If possible and safe to do so, samples should be collected of any materials involved such as broken glass or spilled chemicals. Speak to everyone involved Interview all those involved in the accident: casualties, witnesses, supervisors and line managers as soon as possible after the accident. Be impartial and objective - the aim of the investigation is to prevent a recurrence of the accident, not to blame people. Reassure interviewees about the purpose of your investigation it is to find out exactly what happened and why, so that other accidents can be prevented in the future. Its purpose is not to criticise or to blame individuals. The investigator is seeking their help in identifying what went wrong and what needs to be changed to make arrangements better and safer. Encourage interviewees to describe events in their own words. Remember that they may be upset and not thinking clearly. Be prepared to go back over some points to check facts with them. Do give interviewees a chance to answer questions without interrupting them. Avoid the 'machine gun' style of firing questions at them! Avoid asking questions in a way that will put the interviewees on the defensive and make them reluctant to co-operate, for example 'Didn't you know...?' or 'Why didn't you bother to...'

3 Ask open questions Who? What? When? Where? And How? Discourage unsubstantiated opinions, guesswork or rumours about who or what was at fault. Separate facts from hearsay. Don't jump to conclusions before you have evidence. If you have ideas about contributory factors, check those during your investigation but try to keep an open mind. Take brief notes during the interviews. Read through them as soon as possible afterwards and make sure all points are recorded clearly. Obtain Records Risk assessments, local codes of practice and instruction manuals for equipment should between them set out the agreed arrangements for the work. Recent inspection and test records if applicable, training records and any reports of similar previous accidents will also be helpful. Review Information Check through all the available information and identify any gaps, contradictory statements or anything else that you are not sure of. More information could be required or new evidence may be obtained which will need to be explored. Decide what more you need to know and who to ask. Find the Causes When you have all the facts and information from your investigation, you can identify the contributory factors and the causes of the accident. Do this by asking yourself two questions Would this accident have happened if that factor was not present? For example, if the casualty had used the equipment properly, would the accident still have happened? Why was that factor present? For example, why didn t the casualty use the equipment properly? If the answer is that they had not been trained, why had they not been trained? Don't settle too quickly for the easy answer - look for the immediate and underlying causes of the accident. The immediate cause may be that the casualty slipped on a wet patch of floor, but the underlying causes could be that the equipment was leaking because it had not been maintained on schedule, and that was because renewal of the maintenance contract had been missed this year. Human behaviour is common to all accidents, even indirectly. For example, a manager may buy the wrong equipment because they do not fully understand the job and did not involve the staff in the purchase. An accident then occurs because the users make their own modifications to the equipment simply to get the job done on time. Remember too that what seems to be carelessness can be a symptom of other faults - was the casualty too rushed because of a late delivery of the materials, poorly trained due to language barriers? Was the individual unfamiliar with the premises?

4 Recommend Remedial Actions The actions you recommend should relate to the key causes and contributory factors that have been identified in the investigation. Remedial actions could include rearranging workplace layout; changing the way that tasks are carried out; different equipment, revising local codes of practice; more training; increasing awareness of hazards. Sometimes the investigation will have highlighted weaknesses in arrangements that are not directly related to this particular accident. Include these in your recommendations for improvements as they could be important to prevent problems in the future. Reporting investigations Report your investigation findings, in writing, to the Dean of School or Director of Office. There is space for a short investigation report on the Accident Report Form. For longer reports, attach any separate sheet(s) to the Report Form associated with the accident, or send to the Safety Unit if the accident report has already been submitted. For long investigation reports, consider using the headings in the Appendix Check the Recommended Actions are Effective Follow up your report by checking that: corrective actions have been taken. actions actually deal with the identified causes. actions do not create new hazards. REMEMBER! P R O B E Persistence - find out what really happened and why. Respect - for people you interview. Open mind - don't jump to conclusions. Background - investigate immediate and underlying causes. Explain - fully and clearly in your report and recommendations.

5 Headings for Accident Investigation Report Appendix Date and time of accident: Person(s) involved/injured: Location (campus, building, which room number, which stairs/corridor and floor level, exactly where in corridor): Investigation carried out by: Person(s) consulted during investigation (names, job title/company/school/office and date): Other sources consulted during investigation (eg manufacturers handbooks, risk assessments, training records): Details of accident (factual description of what the individual was doing and what happened, what injuries sustained): Immediate actions taken (eg first aid given, action to make area safe): Details of any sick leave taken or alternative duties assigned to the injured person following the accident: Witness and other accounts (attach separate page if necessary): Background information (eg brief explanation of the task, purpose and operation of the equipment, measurements, sketch of the area, environmental conditions at the time): Any other relevant information (eg other similar accidents, inspection findings): Immediate and underlying causes: Action(s) taken or proposed to prevent recurrence (short-term and longer-term measures): Signature(s) of investigator(s) and date of report: