Conducting an Accident/Incident Investigation

Version:03

Page:1 of 2

WORK INSTRUCTIONIssue Date:26 October 2000

Authorised by:Marjorie Dickenson

1.PURPOSE

The purpose of accident investigation is undertaken to identify causes with the aim of preventing a recurrence. It should:

  • Identify other potential causes of the accident/incident.
  • Comply with statutory requirements e.g., OHS Act 2000, Notification of Accidents Regulation 10990.
  • Ensure remedial actions have been/will be taken.

An accident investigation has the following objectives:

  • Identify all of the factors that contributed to the accident/incident.
  • Ensure that responsibility for issues raised / corrective actions are allocated to appropriate personnel.
  • Ensure that the issues raised / corrective actions are addressed.
  • Identify the OH&S Management systems that have allowed the situations/conditions to occur.

2.SCOPE

The work instruction applies to the investigation of all accidents and incidents.

3.REFERENCES

Occupational Health & Safety Act 2000, Notification of Accidents Regulation 10990

Form – Accident / Incident Investigation.

4.RESPONSIBILITY

Manager/Supervisor of the injured person / Undertake accident/incident investigation
OH&S Representative / Undertake accident/incident investigation
Persons with engineering or other specialist skills, if appropriate / Undertake accident/incident investigation

Personnel conducting the accident / incident investigation must have knowledge of the workplace and the procedures concerned, and appropriate technical knowledge in the fields of:

  • causes of accidents;
  • equipment and processes;
  • personnel management; and
  • ability to gather evidence objectively and to determine the underlying causes of accidents.

5.ACTION / METHOD

An effective system of investigation relies on the following strategies:

  1. Prompt reporting of accidents - it is important that evidence is not disturbed prior to the investigation.
  2. Immediate control actions - to ensure that further accidents do not occur.

5.1.Levels of Accident Investigation

There are two levels of accident investigation:

  1. Immediate Causes (situations immediately preceding the event)
  1. Unsatisfactory Conditions such as:
  2. Buildings and Structure - stairways and paths, electrical/water supply, warnings signs, etc.
  3. Equipment - controls, isolating/safety devices, defective equipment, etc.
  4. Procedural - work practices, procedures, etc.
  5. Environmental - ventilation, noise, lighting, fumes/dust, etc.
  1. Unsatisfactory Practices such as:
  2. Buildings and Structures - failure to remedy slippery surfaces, failure to comply with access/egress restrictions.
  3. Equipment - inadequate PPE, incorrect tool or equipment failure to report obvious hazard, etc.
  4. Procedural - incorrect lifting techniques, failure to wear PPE, variations in safe working practices, etc.
  5. Environmental - failure to activate emergency, ventilation, fume, dust, noise controls.
  1. Underlying (REAL) Causes
  2. Failure of one or more management systems which allowed the unsatisfactory conditions/practices to be present.
  3. Preventative Systems: Risk identification, assessment and control, standard work procedures, maintenance and testing procedures, hazard reporting and investigation, etc.
  4. Support Systems: Induction/Specific/ongoing training.
  5. System Breakdown Management: Emergency procedures, accident investigation, workers compensation and rehabilitation.
  6. Evaluation Systems: OH&S inspections, system reviews, internal audits, quality control evaluation.

5.2.How to Complete an Accident/Incident Investigation

Using the SimuLab form 05-101, Accident / Incident Investigation:

STEP 1: Get the facts

  • Note observations.
  • Eye Witnesses.
  • Photo/sketches.

STEP 2: Determine the sequence of events (who, what, when, where, why)

  • Identify all conditions at the time of the incident.
  • Identify all variations from standard practices.

STEP 3: Identify the Management Systems Failures for each of the above categories

  • Consider possible remedies.
  • Select the best solution in terms of effectiveness, cost, meeting acceptable standards.

STEP 4: Determine Remedial Action This may include:

  • Modifications to the workplace or equipment.
  • Changes in work practices.
  • Provision of training.

STEP 5: Follow-up and Evaluate

  • Effectiveness.
  • Acceptability.

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