Accident Investigation

Objective: To summarize the accident, determine root causes, and provide the client with recommendations and resources to prevent reoccurrence.

Investigation

Conducted By

Time of Investigation
Date of Investigation
Company
Company Contact
OSHA Notified? / ( ) Yes ( ) No OSHA: 1-800-321-6742

Personal Data – Injured Worker

Name

Address
Telephone
Age
Job Title
Hire Date
Time in Position
Location of Incident
Date/Time of Incident
Specific Task Performed at Time of the Incident
Prior Training Received for Task Performed
Nature of Injury
(fracture, amputation, etc.)

Result of Incident

/ ( ) Near Miss ( ) Property Damage ( ) Injury ( ) Fatality

Subrogation Potential

Property Owner

General Contractor
Equip. Manufacturer
Customer
Other

Witness

Name

Address
Telephone
Job Title
Hire Date
Time in Position
Task Performed at Time of the Incident
Proximity to Incident
Witness: / ( ) saw the actual accident ( ) heard the accident ( ) saw immediate result of accident

Witness’s Account of Incident

Witness

Name

Address
Telephone
Job Title
Hire Date
Time in Position
Task Performed at Time of the Incident
Proximity to Incident
Witness: / ( ) saw the actual accident ( ) heard the accident ( ) saw immediate result of accident

Witness’s Account of Incident

Incident Analysis

Incident Description
Attach sketches, diagrams, or photos as appropriate
Direct Causes / Yes / No / Comments
Operating equipment without authority
Using equipment improperly
Defective tools or equipment
Inadequate guards or barriers
Safety devices removed
Operating at improper speed
Improper loading or overloading
Servicing equipment in operation
Making safety devices inoperable
Failure to secure or make safe
Failure to use required PPE
Failure to use PPE properly
Improper/inadequate PPE
Substandard Housekeeping
Failure to follow company safety rule
Fire and explosion hazard
Inadequate ventilation
Unsafe ground conditions
Drugs/alcohol suspected

Underlying Causes

/ Yes / No / Comments
Inadequate supervision
Lack of knowledge
Inadequate engineering
Lack of skill
Inadequate purchasing
Physical or mental stress
Inadequate maintenance
Inadequate motivation
Inadequate tools/equipment
Excessive wear and tear on equipment

Recommended Corrective Actions

Action

Person Responsible For Action
Date to Be Completed

Recommended Corrective Actions

Action

Person Responsible For Action
Date to Be Completed

Recommended Corrective Actions

Action

Person Responsible For Action
Date to Be Completed

Recommended Corrective Actions

Action

Person Responsible For Action
Date to Be Completed

Recommended Corrective Actions

Action

Person Responsible For Action
Date to Be Completed

Interview Techniques

  • Conduct in a neutral place free from distractions should be chosen for the interviews when feasible.
  • Create an environment in which the interviewee will be comfortable.
  • Do not treat the interview like an interrogation.
  • Before asking questions, ask the interviewee to provide a description of the events in his/her own words. Do not interrupt during this description.
  • Ask open-ended questions (sample questions attached).
  • Allow time between the interviews to reflect on information obtained and whether this information affects the questions planned for the next interview.
Site Review
  • Sketch out accident if possible.
  • Take distance measurements, etc.
  • Ask for copies of training records, equipment inspection/maintenance logs, operator’s manuals, engineer reports or findings, etc.
  • Note manufacturers of affected equipment, model numbers, etc.
  • Ask for and verify any controls implemented post accident.

Sample Accident Investigation Questions

HOW

1)How did the injury occur?

2)How could this accident have been prevented?

WHO

1)Who else saw the accident?

2)Who had assigned the person to the work task?

3)Who had trained the person on the hazards and protective measures for this task?

4)Who else was involved?

WHAT

1)What was the person doing when injured?

2)What had the person been instructed to do?

3)What tools/equipment was the person using?

4)What operation was the person performing?

5)What training had been given?

6)What protective equipment was being used?

7)What extenuating circumstances were involved?

8)What safety rules were in place to prevent this type of accident?

9)What safety rules were being followed?

10)What were the environmental conditions (i.e., lighting, floor surface, etc.)?

WHEN

1)When did the accident occur?

2)When did the person start this task?

3)When had the supervisor last checked on job progress?

WHY

1)Why was the person injured?

2)Why did the person do what they did?

3)Why wasn’t protective equipment used?

4)Why weren’t specific instructions issued?

5)Why didn’t the person check with the supervisor when they noted things weren’t as they should be?

6)Why did the person continue to work under these circumstances?

WHERE

1)Where was the supervisor at the time?

2)Where were the witnesses when the accident occurred?

Accident Investigation

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