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Accident

Investigation

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The Five Stages of anAccident Investigation

Reporting

Gathering information

Analyzing information

Identifying risk control

measures Action planning andimplementing

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What should I know whenmaking the analysis and

conclusions? At this stage of the inestigation most ofthe facts a"out what happened and howit happened should "e known# $his has

taken considera"le e%ort to accomplish"ut it represents only the &rst half of theo"jectie# 'ow comes the key uestionwhy did it happen* $o preentrecurrences of similar accidents+ theinestigators must &nd all possi"leanswers to this uestion#

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What should I know whenmaking the analysis and

conclusions? ,ou hae kept an open mind to all

possi"ilities and looked for all pertinent

facts# $here may still "e gaps in yourunderstanding of the seuence of eentsthat resulted in the accident# ,ou mayneed to reinteriew some witnesses to

&ll these gaps in your knowledge#

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What should I know whenmaking the analysis and

conclusions? -hen your analysis is complete+ write downa step"ystep account of what happened(your conclusions) working "ack from themoment of the accident+ listing all possi"le

causes at each step# $his is not e.tra work/it is a draft for part of the &nal report# Eachconclusion should "e checked to see if/

it is supported "y eidence

the eidence is direct (physical ordocumentary) or "ased on eyewitnessaccounts+ or

$he eidence is "ased on assumption#

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Why shouldrecommendations be

made? $he most important &nal step is tocome up with a set of wellconsideredrecommendations designed to preent

recurrences of similar accidents# 0nceyou are knowledgea"le a"out thework processes inoled and the

oerall situation in your organization+it should not "e too di1cult to comeup with realistic recommendations#

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Recommendations

should"e speci&c

"e constructieget at root causes

identify contri"uting factors

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'eer make recommendations a"outdisciplining a person or persons who may

hae "een at fault# $his would not only "ecounter to the real purpose of theinestigation+ "ut it would jeopardize thechances for a free 2ow of information in

future accident inestigations# In the unlikely eent that you hae not

"een a"le to determine the causes of anaccident with any certainty+ you pro"a"ly

still hae uncoered safety weaknesses inthe operation# It is appropriate thatrecommendations "e made to correctthese de&ciencies#

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How should follow!u"

be handled?

3anagement is responsi"le for

acting on the recommendations inthe accident inestigation report#

$he health and safety committee+ if

you hae one+ can monitor theprogress of these actions#