Accident Investigation Fact-Finding
Workplace accidents are unplanned and unintentional events that result in harm or loss to personnel, property, production, or nearly anything that has some inherent value to a business. Accidents are rarely simple and almost never result from a single cause. Most accidents involve multiple, interrelated causal factors. Accidents can occur whenever significant deficiencies, oversights, errors, omissions, or unanticipated changes are present. Any one of these conditions can be a precursor for an accident; the only uncertainties are when the accident will occur and how severe its consequences will be.
Understanding how to prevent or control accidents requires an understanding of the sequence of events leading to an accident – this is called the fact-finding phase of an accident investigation, and the results can assist in identifying and implementing countermeasures.
When conducting the fact-finding phase of an investigation, the investigator or the investigating team should consider the following:
Gather evidence from all sources available.
Get information from any written reports, as well as by onsite observations.
Interview witnesses as soon as possible after an accident.
Inspect the accident site before any changes occur.
Take photographs and make sketches of the accident scene.
Record all pertinent data on maps.
Get copies of all reports, documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities.
Keep complete and accurate notes in a bound notebook.
Record pre-accident conditions, the accident sequence, and post-accident conditions.
Document the location of victims, witnesses, machinery, energy sources, and hazardous materials.
Include in the notes taken during the investigation or in the later analysis of data, any particular physical or chemical laws, principles, or properties that may explain a sequence of events.
Gather data during the investigation that may lend itself to analysis by these laws, principles, or properties.
Include an extended discussion of these laws, principles, or properties in an appendix in the final report.
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