HOW TO INVESTIGATE AN ACCIDENT - ASSESS RISK

1 HOW TO INVESTIGATE ANACCIDENTWhen investigating an ACCIDENT you should be concerned withtrying to identify the route cause of the ACCIDENT , not justthe obvious cause: For example: ACCIDENT : Teacher falls down a set of stairsObvious Case: The treads on the stairs are wornRoot Cause: There is no maintenance system in placeThere is no system for inspection of thepremisesThere is a lack of a management systemprogrammeAn ACCIDENT investigation that does not seek to identify theroute cause in not a complete ACCIDENT investigation should be carried out byindividuals that are competent to do so.

2 The followingguidance is designed to aid the investigative IN AN INVESTIGATIONOBTAIN FACTSDETERMINE THE CAUSESDETERMINE THE CHANGES NEEDEDRECORD THE FINDINGSCOMMUNICATE THE FINDINGSREVIEW ACTIONOBTAIN THE FACTSE stablishing what is relevant and what is not can be timeconsuming. However this information can be obtained by:Inspecting the immediate scene and equipmentInterviewing the person directly involved with the accidentInterviewing witnesses to the accidentReviewing procedures and trainingInspecting the immediate scene and equipment:The ACCIDENT scene should be inspected as soon as possibleafter the ACCIDENT .

3 Particular attention should be given tothe following to see if any of them had a bearing on theaccident potential:Positions of peopleAny personal protective equipmentTools and equipmentOrderliness/tidinessProceduresW herever appropriate, photographs and/or sketches should betaken of the scene. This is of particular importance wherethere is a likelihood of the scene being disturbed tomake the area :Ideally this should be done in familiar surroundings so asnot to make the person being interviewed feel the person is not too seriously injured then the accidentsite is ideal as the person can explain what this should be an interview to determine the factsnot an interrogation.

4 Witnesses should be interviewed one ata timeReviewing procedures and training:The work procedures set out in appropriate guidance and anyrisk assessments should examined to see if they existed andwere adequate, if they were understood and is also important to establish:Any training received relevant to the accidentAny past incidents/accidentsAny risk assessments in relation to that particularactivityto see if any weaknesses have been previously identifiedDetermine the causes:After all the facts have been ascertained the causes can causes: The obvious causes are easy to are brought about by an unsafe act or condition.

5 Unsafeacts usually stem from poor safety attitudes and indicate alack of proper training or Causes:These are personal or job factors that arebrought about by failures in organisation and themanagement s safety programme. This can include factors suchas;Lack of supervision or disciplineLack of trainingLack of management awarenessDetermine what changes are neededThe purpose the investigation is to prevent a do this some practical measures must be recommended andcarried out that will demonstrate a commitment to reducethis identified risk.

6 The remedial action may be short and/or long term and may involve changes to the physicalenvironment putting in place new guarding onmachinery and/or procedural changes ensuring an adequatetraining findingsThe findings of every ACCIDENT investigation must berecorded in a systematic way to enable the report to be readby the appropriate people who are responsible for reviewingand implementing necessary changes. It also provides ahistorical record of the ACCIDENT that may be useful in thefuture. In many cases it may be appropriate to record thefindings on existing forms EDAF1.

7 However, where moredetailed reports are required, then details of the accidentinvestigation should be recorded separately and attached toany completed ACCIDENT findingsGood communication is a very important part of the safetyeffort. Information of an ACCIDENT and remedial actionsshould be passed to all relevant staff who may encountersimilar actionWhere action has been implemented as a means of reducing therisk of an ACCIDENT reoccurring, those actions must beperiodically reviewed to ensure that they remainappropriate.