All untoward incidents, which could not be prevented from occurrence, indicate that failures have occurred. It is very essential to draw lessons from it, improve the situation and avoid it in future. Site personnel and work in-charge need easy, simple and readily applicable technique to learn and follow.
The purpose and reasons behind Accident Investigation can be summarized as follows:
- For legal reasons
- For claim management
- For staff morale
- For Records, Data Gathering & Disciplinary Uses.
The immediate action on occurrence of any accident is to save the affected persons and arrange for their rescue, first-aid and requisite medical care. Simultaneously or with no delay, the abnormal situations are to be normalized and made safe, with least or no change in the scene of the occurrence (take photographs to capture the original scene of occurrence as far as possible) which shall facilitate incident investigation.
Once the immediate dangers have been dealt with and casualties attended to, a decision should be made regarding the type and level of investigation that is needs.
Secure the scene as soon as possible to prevent it being altered. Collect witnesses’ details quickly, before they start to move away. In some cases it may help to remove witnesses from the scene and ask them to wait in a separate area. If there are many witnesses it may be better to separate them from each other to prevent collusion or contamination of their testimony. Collect factual information from the scene and record it.
- Taking physical evidence.
The investigator should come prepared with the appropriate equipment to record this information. Once the scene has been thoroughly examined, move on to the second source of information: witnesses. Witnesses often provide crucial evidence about what occurred before, during and after incident. Once witnesses have been interviewed, move on to the third source of information: documentation.
- Company policy
- Risk assessments.
- Training records.
- Safe system of work
- Maintenance records.
- Disciplinary records.
- Internal accident report forms.
- Log book entries
- Computer printouts relevant to the situation.
The purpose here is to draw conclusions about the immediate and root causes of the incident. These will be the things that occurred at the time and place of the accident. Underlying or root causes are the things that lie behind the immediate causes, such as:
- Failure to adequately supervise workers.
- Failure to provide appropriate PPE.
- Failure to provide adequate training.
- Lack of maintenance.
- Inadequate checking or inspection.
- Failure to carry out proper risk assessments.
Identify Suitable Control Measures
Once the immediate and underlying causes of the accident are known, appropriate control measures can be identified. Control measures must be identified to remedy both the immediate and underlying causes. Perhaps the most important questions to ask when identifying control measures are:
- If this action is taken, will it prevent this same accident from happening in exactly the same way at this location?
- If this action is taken, will it prevent other similar types of accident from happening in similar locations in the future?
If the answer to both of these questions is “no”, then you need to identify other control measures.
Plan the Remedial Actions
An accident investigation should lead to corrective action being taken. When the action plan is being prepared, appropriate immediate and interim control measures must be given suitable priorities and timescales. Unsafe conditions must not be allowed to persist in the workplace. Dangerous practices and high risk activities must be dealt with immediately. This means that immediate action must be taken to remedy such circumstances when they are discovered. Machinery and equipment may have to be taken out of action, certain work activities suspended, and locations evacuated. These responses cannot be left until the investigation has been completed. They will have to be implemented immediately to ensure safety while the investigation is in progress. There may be interim control measures that can be introduced in the short to medium term to allow work to proceed while longer-term solutions are pending.
Underlying causes will often demand significant time, money and effort to remedy. It is essential, therefore, that the remedial actions that will have the greatest impact are prioritized and timetabled first. There may be actions that have to be taken(to address a management weakness or to achieve legal compliance) that will not be as effective in preventing future accidents. These actions should still be taken, but with a lower priority.