Accident investigations help determine how and why events occurred. By using the information gained through an investigation, a similar, or perhaps more disastrous, accident may be prevented. Accident investigations should be conducted with prevention in mind, and not to place blame.
The actual procedures used in a specific investigation will depend on the nature and outcome of the accident. Senior management should appoint an investigator to be in charge of the investigation or to head up the investigation team, if a team approach is used to analyze the facts. The investigator should define the scope of the investigation and select the investigation team, assigning, preferably in writing, specific responsibilities for each person on the team. The investigating team composition depends on the scope of the accident and could consist of just the investigator.
The following steps offer a recommended, systematic approach to conducting an accident investigation:
- Develop a preliminary briefing that includes a description of the accident, with damage estimates; normal operating procedures; maps (local and general); location of the accident site; a list of witnesses; and events that preceded the accident.
- Visit the accident site to get updated information.
- Inspect the accident site.
- Have the area secured; however, the scene should not be disturbed unless a hazard exists.
- Prepare the necessary sketches and photographs, labeling each carefully and keeping accurate records.
- Interview each victim and witness. Also interview those who were present before the accident and those who arrived at the site shortly after the accident. Accurate records of each interview should be kept – a tape recorder can be used, if desired and approved.
- Determine what was not normal before the accident, where the abnormality occurred, when it was first noted, and how it occurred.
- Analyze the data obtained in step 7.
- Repeat any of the prior steps, if necessary.
- Determine why the accident occurred, a likely sequence of events and probable causes (direct, indirect, basic), and alternative sequences.
- Check each sequence against the data from step 7.
- Determine the most likely sequence of events and the most probable cause(s).
- Conduct a post-investigation briefing.
- Prepare a summary report, including the recommended actions to prevent a recurrence.
- Distribute the report according to applicable instructions.
An investigation is not complete until all data is analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation will proceed simultaneously during the investigation.
COPYRIGHT ©2005, ISO Services Properties, Inc.