Accident Investigation and Reporting

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Occupational Health & Safety

Practitioner

Reading

ACCIDENT INVESTIGATION ANDREPORTING

January 2009


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Contents

OVERVIEW.....................................................................................................................1

SECTION 1: GETTING STARTED.................................................................................2

SECTION 2: THE INVESTIGATION ..............................................................................7

SECTION 3: RESEARCH ............................................................................................14

SECTION 4: ANALYSIS...............................................................................................16

SECTION 5: REPORTING...........................................................................................20

SUMMARY ....................................................................................................................24

Government of Western AustraliaDepartment of Commerce

Published by WorkSafe,

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Tel: Toll Free 1300 307 877.

Email: [email protected]

www.worksafe.wa.gov.au/institute

The SafetyLine Institute material has been preparedand published as part of Western Australiascontribution to national OHS skills development.

2009 State of Western Australia. All rights reserved.

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Before using this publication note should be taken of the Disclaimer, which is published at the

SafetyLine Institute website.
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READING ACCIDENT INVESTIGATION AND REPORTING

Section 1: GETTING STARTED

IntroductionAn accident has happened at work. - Perhaps someone has been

injured. - What is the basic first step that needs to be taken?

Where do we start? The initial and fundamental step to

commence the process of accident investigation and reporting is

the notification to management that an accident or incident has

happened. The person best placed to initiate this action is the

person who was involved in the accident or incident and it should

be made to their immediate superior. The workplace should have a

system in place for notification and recording of all incidents andinjuries that have happened at the workplace.

After the accident or incident has been notified and recorded, there

should also be an automatic system in place to enable notification

to the appropriate personnel responsible for investigating these

occurrences including elected worker health and safety

representatives (if any).

What can we achieve from conducting an accident investigation?

We can't stop the person from being injured. We can't stop theequipment involved in the accident from malfunctioning. We can't

stop the plant, building or equipment from being damaged or

rendered unserviceable.

We have already lost enough productivity as a result of the

accident, firstly from the equipment being out of service, then

waiting for the ambulance to arrive, and now trying to replace the

injured person, and the rest of the operators seem to be working

slower than usual. We have orders to fill and deadlines to meet. If

we conduct an investigation as well, we will have a huge loss of

productivity, people away from their usual job being interviewed,

consequently other employees relying on their work are at a

standstill. To investigate is reactive. We need to be pro-active.

Interesting and compelling reasons for not conducting an

investigation. Loss of productivity! Wow! - productivity - a buzz

word - let's face it, our pay and pay rises are based on productivity,

our employers very viability is productivity based.

PAGE 2 SAFETYLINE INSTITUTE JANUARY 2009


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1.1 Why investigate?

Agreed, you cannot stop the person being injured, you cannot stop

the equipment or plant being damaged, you cannot stop the loss of

productivity that has occurred. You can, however, establish the

causal factors of the accident from which the hazard or hazards

can be identified. You can then identify the risks associated with

the hazards and develop preventative strategies to reduce the risk

of this or similar accidents happening, at this or similar workplaces,

again.

The reduction of lost time injuries in a workplace, industry, State or

Country has a major impact on productivity, initially due to the

obvious factors outlined above and ultimately circumstances such

as reduced costs due to effective reductions in worker's

compensation insurance costs, public liability insurance costs,

hospital operating costs and legal fees associated with permanent

disability claims.

The direct cost of worker's compensation claims does not take into

account the indirect or uninsured costs of an accident. The

indirect costs or expenses associated with an accident include:

down time of machinery and equipment, training and re-training of

employees to take over the injured persons duties, loss of ordersdue to inability to supply or late delivery, legal costs associated

with civil claims and prosecutions mounted by enforcement

agencies and the cost of any penalties or fines imposed.

Conservative estimates place uninsured, indirect costs of an

accident between 4 and 7 times the insured cost whereas Davis

and Teasedale (1995) suggest the ratio is between 8:1 and 36:1.

The other compelling reason for investigating a work related

accident is to ensure the employer is fulfilling their legal duty of

care obligation. Any employee, their partners, parents, childrenand friends have the right to expect the employee to return from

work each day in the same state of health that they were when

they left for work. There is a long established legal duty of care

under common law on an employer to provide a working

environment that will enable this expectation to be attained.

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 3


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1.2 Who investigates?

Having established that an investigation is desirable, it must then

be determined who is to conduct the investigation. Accident

investigations fall into two main categories, internal and external. A

workplace has no control over external investigations unless it is

one they have commissioned on their own behalf.

An investigator is a facilitator. A person trained to seek out, record,

and report on the circumstances and causal factors, draw

conclusions and make recommendations to reduce the risk of a

recurrence of the circumstances.

If an accident happens at work, regardless of whether a person is

injured or not, there is a strong chance that the employer's duty of

care to provide a safe workplace, free of hazards, has broken

down. For this reason alone, regardless of any other reasons, the

employer should investigate the accident to establish and eliminate

the hazard and the associated risk that ultimately caused the

accident.

1.3 Internal investigations

The workplace should have a competent, trained person who is

delegated to manage safety at the workplace, and included in this

delegation should be a requirement to investigate all accidents and

incidents. In addition to this employer nominated safety officer, it is

highly desirable to have an elected health and safety

representative, elected by workers at the workplace, as prescribed

in the majority of OHS legislation, who also should investigate and

prepare a report on the accident or incident.

These reports, together with enterprise accident and incidentstatistics, should be reviewed at regular safety committee

meetings, where additional comments, ideas and expertise may

throw fresh light on causal factors or preventative strategies.



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1.4 External investigations

Depending on the seriousness of the accident or the injuries

received, an investigation may be carried out by many various

investigators apart from any investigation carried out internally by

the enterprise.

The first type of external investigator that may be encountered is

one representing a Statutory Authority. That is a person

representing a Government Agency which administers legislation

which embraces the activity being undertaken at the workplace

involved. This investigator may represent the Coroner or Police

Service if the injured person dies, a health and safety enforcement

agency (WorkSafe WA, Comcare, Bureau of Air Safety, etc.), or a

public utility (fire service, electricity, gas or water). These

investigators have a legal right to be at the premises to interview

witnesses, collect evidence and in some cases stop the work

process.

The next type of external investigator that may be encountered is

private inquiry agents or consultants. These investigators are

normally commissioned to undertake an investigation by an

insurance company representing the worker's compensation

insurer, the public liability insurer of the employer or the publicliability insurers of plant or equipment involved in the accident.

These investigators do not have the same, or any, legal rights as

those representing a statutory authority. This type of investigation

is normally only undertaken where it appears that the injured

person may have suffered an injury that will result in some form of

permanent disability that may result in civil litigation, or where

there has been substantial damage to plant, equipment or property

that may also result in civil litigation.

Once again these investigators do not have the same rights asinvestigators from a statutory authority. They do, however, have

some rights under discovery provisions of the legal system.

Employers should refer these matters to their legal representative

or insurance company.

If the injured person was employed by a Government authority, or

if a statutory authority investigated and reported on the incident,

there may be some access to these documents by members of the

public and interested parties nominated above, or indeed any

person, under the provisions of Freedom of Information legislation.



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1.5 When to investigate accidents

The ideal time to investigate accidents is now! As close as

possible to the time of the accident is the most desirable, before

evidence starts to deteriorate. Obviously the physical location ofthe accident site compared to the location of the investigator will

have a significant bearing on how quickly an accident or incident

investigation will commence. Preferably the investigator should be

one of the first people on the scene, to enable the scene to be

secured and evidence preserved or captured.

If the investigator cannot get to the accident scene immediately,

they should arrange with some other responsible person to secure

the scene and protect the evidence. Depending on the time lapse

between the incident and the commencement of the investigation,

it may be desirable to have another person take photographs if

practicable and prepare a list of persons who were at or near the

scene, who may be potential witnesses.

The deterioration of evidence can take many forms such as

deterioration due to weather conditions (wind, rain, temperature

etc.), destruction or relocation due to the need to remove the

evidence to rescue an injured person, destruction due to

unauthorised persons or vehicles moving around the immediatevicinity; and the most fragile of all evidence, the recollection of the

human mind and the ability of a persons sub-conscious memory to

fill in gaps in what they saw or their own visual experience being

corrupted by another person's verbal description of what

happened. These factors will be discussed further in the

investigation phase.



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Section 2: THE INVESTIGATION

An investigation is a methodical, systematic, unemotional

undertaking to collect and interpret information about an event to

establish the extent of an injury or loss, why it happened and to

analyse the processes involved to minimise the risk or prevent a

recurrence. The investigation will normally result in the preparation

of a logical, sequential report of the events with recommended

preventative strategies.

2.1 Pre-planning

The amount of pre-planning required is dependent on the number

and type of discreet workplaces the investigator is likely to be

called to, and their geographical location. A major need for pre-

planning is to enable an investigator to reach an investigation site

as soon as possible after the event and to have all of the

equipment required to conduct the investigation at their disposal.

If a person such as a health and safety representative is only

responsible for investigating accidents in their immediate

workplace or location within the workplace, their pre-planning willprobably only require adequate stationery to be physically at hand,

together with a written list of where all other items that may be

required, can be located.

On the other hand, if an enterprise group safety officer has

workplaces that are spread throughout the State or Country they

would need to have a fully equipped case, bag or other container

ready to go at any time. The amount of equipment to be taken will

depend on the mode of transport to be utilised (e.g. motor vehicle

or aircraft). This situation is the scenario faced by most external

investigators.



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Basic equipment that may be required includes:

mobile telephone with back-up power pack, for communication;

camera, with spare film, flash and batteries;

personal protective equipment (safety glasses, hard hat, safety

shoes, hearing protection, gloves, respiratory protection, wet

weather gear);

recording equipment, with spare tapes, batteries;

stationery, writing/sketching materials, pre-printed forms,

handouts;

containers for taking and storing samples; and

small hand tools, torch, pliers, screwdriver, tape measure.

Other items that may need addressing are transport,

accommodation and expenses.

If a motor vehicle is to be the chosen form of transport, particularly

to distant or remote locations, the vehicle should be suitable for

that task and ready for use (fuel, roadworthiness,

maps/directories). If an aircraft is to be used, bookings are

required, transport at the destination arranged, accommodation

booked, etc, as well as financial arrangements for paying for these

services (cash advance, company credit card, purchase order

book).

2.2 Commencing the investigation

The investigation involves the collection of evidence some of it

extremely fragile, consequently it is highly desirable to collect the

evidence in descending order of fragility. Fragility of evidence can

be described as breakage, distortion or loss which makes theevidence unusable. One of the most fragile pieces of evidence is

the recollection of a witness, as this can change with time,

particularly when their sub-conscious memory starts to fill in the

events they saw with what other people have stated they saw or

even theorised what might have happened.



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The rescue of an injured person and securing the accident scene

from contamination by other people moving around the area is of

the highest priority. It may be necessary to make the scene safe

before attempting to commence first aid on an injured person.

Once the injured person has been treated and removed then the

scene should be secured to ensure the safety of yourself and other

persons from any hazards that may still exist, and to restrict

access to the scene so as to leave it as close as possible to the

conditions existing at the time of the accident.

If it is necessary to disturb the site to either remove the injured

person or to secure any hazards, take a video tape recording or

photographs if practicable. Alternatively make a note or sketch of

what is done or what the scene looked like prior to the changes, as

soon as possible.

2.3 Examination

Overview or preliminary investigation

During the preliminary investigation an overview of the events is

obtained. It is a sound practice to make brief written notes on what

steps you have taken and when, and who you speak to and what

information they can contribute. The investigator then has a

chronological list of actions taken which will enable prioritising

further actions, particularly which witnesses to interview and in

what order.

The overview phase allows the investigator to get a feel of the

workplace, what they do, what they produce, a broad picture of the

workplace, the macro view. It enables the investigator to locate the

accident scene in the overall plan of things and where this scene is

located in the process. Depending on the size of the workplace,this broader macro view is invariably the extent of working

knowledge of the workplace by some senior management.



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Accident scene

The investigator then turns their attention to the smaller, more

confined accident scene. This zone is where a lot of the physical

evidence will be located, and this is the area that should besecured and preserved immediately.

On arriving at the accident scene it is essential that the investigator

makes an assessment of any hazards that may be present, either

the pre-existing cause or hazards that have arisen as a result of

the accident that could cause further injury or harm. These

hazards should be eliminated, controlled or managed so as not to

place any other person at risk.

At this stage it is desirable to take photographs of the accident

scene, a video recording if equipment is available and sketches or

notes about the site. It may be that items, plant or equipment

which were not originally thought to be involved in the accident,

subsequently are identified to have had a contributory effect. A

visual image will record all items and their location relative to each

other and the immediate accident site.

Witnesses

A witness is a person who has first hand knowledge of some fact related,directly or indirectly, to an accident or incident.

The next step is to identify and speak to witnesses, initially briefly,

to ascertain what information they can contribute to the actual

event and the normal procedures that were in place. As each

factor is identified, appropriate photographs, samples and

sketches should be taken or made, together with a notation of the

time this was done.

From this list of witnesses the investigator needs to prioritise theorder in which to interview them, taking into account the fragility of

their evidence, and commencing with eye witnesses to the event

or accident. People who can only advise on the usual work

practice or procedure would receive a much lower priority.



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The investigator then needs to determine the method of recording

what the witness has to say. This will be strongly influenced by the

type of investigation being undertaken. If the investigation is being

undertaken by a statutory authority, it is highly likely that they will

insist on a written, signed statement or a record of interview which

is initially taped and then transcribed into a written format. This

requirement is necessary to preserve the evidence in a permanent

record for reporting to other authorities, and for evidence for legal

purposes if deemed necessary. The main advantage of a record of

interview that is taped is that you have a verbatim record of what a

person said - not what you thought they said.

When taping a record of interview it is important to record on the

tape the time the interview starts and finishes and the time any

interruptions take place. The reason for recording the time is to

have a permanent record of the time it took to record the interview

which can be used to prove that nothing has been added to, or

deleted from, the recorded interview.

Inquiry agents will also take some written statements, once again

for future legal processes if they are commenced.

In other circumstances the investigator may prefer to make notes

of what is said, the ultimate objective is to have a written record ofall the facts so that a word picture can be prepared of all events

leading up to and including the incident or accident, which can

then be presented in a report. Evidence that is collaborated can be

recorded in confidence. Uncorroborated evidence needs to be

treated with caution, although not discounted unless collaborated

evidence refutes it.

Apart from an accident victim, people rarely observe the full

circumstances of an accident or incident and not being trained

observers rarely see in detail what they are looking at and even ifthey do, they cannot remember the detail. The investigator will

need to ask appropriate questions in order to obtain relevant

answers. The investigator should attempt to gain rapport with the

witness. It is a good idea to commence with some general

conversation to relax the person and give them confidence in

replying to questions, for example, conversation about their own

job, their own list of duties and generic questions about the

workplace.



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The investigator also has to be extremely careful not to influence

the witness by the type of questions they ask, any mannerisms

they may display, or any reactions to questions that may give the

impression of the type of answers they should give.

In the preliminary overview of the accident scene and discussions

with potential witnesses, the investigator should be developing a

clear picture of the process that was taking place before and

leading up to the accident or incident. If any gaps appear in the

picture the investigator can then formulate meaningful questions to

elicit information from the witnesses.

Whilst an interview is in progress a witness may provide

information that has not previously been identified or recorded as

part of the process or equipment involved in the accident or

incident. It may be necessary, as a result of this new information,

to change or add to the questions being asked, and in some

cases, re-interview persons who have already been interviewed.

A recorded witness statement, either in writing or electronically,

should be considered as a confidential communication between

two people, and as such, this confidentiality should be respected. It

is perfectly acceptable to use the information gleaned in the

interview in any subsequent report, however the copies of theperson's statement should not be given to a third party without

firstly obtaining the permission of the witness.

Evidence and exhibits

What is the difference between evidence and exhibits? Raymond

Kuhlman in his publication Professional Accident Investigation

categorises evidence into four categories in descending order of

fragility as:

People;

Positions;

Parts; and

Papers

Exhibits are physical evidence which can be used in a Court of

Law.



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People provide eye or ear evidence relating to events prior to,

during and after the accident. This information is recorded as

witness statements as described above.

Positions are the physical location of people and parts prior to, at

the time and after the accident. The position of parts after the

accident can be extremely fragile, particularly if they are removed

or repositioned during recovery of an injured person, or

accidentally due to the site not being adequately secured. To

ascertain the position of people and parts prior to and at the time

of an accident will normally depend on the affirmation of witnesses.

Parts are visible, tangible, material pieces of plant, tools,

equipment, buildings at or around the accident scene that may or

may not have had some influence prior to, during or after the

accident. The examination and inspection of parts that are

suspected of having caused an accident through distortion or

failure may be required to be undertaken by a person who is

appropriately qualified to examine the part, or has sophisticated

equipment required to undertake comprehensive testing. Any

reports or advice provided will form part of the evidence in the

investigation and the person who provides the advice or

information are usually known as an "Expert Witness."

Papers are the most stable, durable part of evidence. They take

numerous forms and consist of written records such as: job

standards, job procedures, operating instructions, maintenance

manuals, maintenance records, induction records, training records,

qualifications of personnel, certificates of competency, contracts

and quotes.



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Section 3: RESEARCH

3.1 Determine existing workprocedures

The research phase of determining existing work procedures is

normally undertaken at the workplace itself, although where an

enterprise has more than one workplace, written procedures may

be located at the head office. Where written procedures are

available, a copy should be obtained and the contents should be

compared with the verbal descriptions supplied by persons,

including the victim, who have performed the duties or functions, or

undertaken the process that was involved in the accident.

These procedures can be analysed to determine any weaknesses

in the system, and compared with similar procedures at kindred

industries.

3.2 Check for similar accidents

Numerous statutory authorities throughout the world produce

executive summaries of accident reports. These are known by avariety of names such as safety alert, safety information,

significant incident reports and significant incident summaries.

These are accessible through various mediums such as safety

magazines, trade and business journals, direct mailing lists, health

and safety libraries and of course the internet. WorkSafes

SafetyLine has one of the best on-line collections of summaries.

The disturbing aspect of reading these summaries is that the same

type of accidents are happening all around the world, time after

time, indicating that people are not learning from accidents inwhich some people have been seriously injured or even died.

On the positive side, the accident that the investigator is examining

is probably not unique. With a little research it is probable they will

locate other accidents that have taken place in very similar

circumstances. By researching these other accidents the

investigator will be able to benefit from other investigators'

research, findings, recommendations and preventative strategies.



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Some investigators attempt to reconstruct the circumstances of the

accident. This is not a recommended practice as reconstruction

goes hand in hand with recurrence. At this stage it is important to

recognise that there is a distinct difference between reconstruction

and re-enactment.

Reconstruction is a rebuilding of the accident and is primarily used

to establish the sequence and reason parts and equipment failed.

Re-enactment is description of events played out, primarily to

obtain time-frames and sequences of events prior to the actual

incident or accident. Reconstruction can be an extremely important

tool, particularly when there are no witnesses to the event and

there is minimal or no physical evidence. Where reconstruction of

the circumstances or part of the circumstances are deemed

necessary, it must be made in a controlled environment.

3.3 Other research

Research is not confined to existing work procedures and similar

accidents. It may be associated with establishing methods of

eliminating a hazard, reducing the risk of the hazard, substitutes

for the hazard, or may relate to preventative methods or strategies.

Research may be undertaken to establish the strength of tools and

equipment, effects of exposure to unseen hazards such as gasses

or electrically induced magnetic fields, remember, all hazards are

not necessarily visible or can be smelt.

The best place to start research is in a library, either physical or

electronic. You are currently operating in the largest resource

library in the world - the information super highway - the Internet.



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Section 4: ANALYSIS

Accident investigation is like peeling an onion. Beneath one layer

of causes there are other layers. The outer layers deal with the

immediate causes while the inner layers are concerned with the

underlying causes such as weakness in the management system.

Trevor Kletz - Learning from Accidents in Industry

4.1 Determine immediate causes

The immediate causes are normally the easiest to ascertain, and it

is essential to establish these to determine any underlying causes.They provide a starting point for the investigation. The immediate

causes will be the details immediately provided by people,

positions and parts. There will usually be tangible evidence

Most of the immediate causes will be established in the early

stages of the investigation when the investigator is gathering

preliminary information, taking photographs, identifying witnesses

and what they can contribute to the investigation. The information

will be gathered from people, position and parts. Paperwork

invariably will not provide information on the immediate cause of

accidents.

Witnesses will provide most of the detail of the immediate causes

with minimal prompting or questioning, particularly when they are

interviewed within a close time frame to the event. Some

prompting may be necessary to obtain confirmation of points

raised by another witness, however, it is essential that the

investigator avoids leading the witness.



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4.2 Determine underlying causes

The determination of the underlying causes will be dependent on

the immediate causes supported by information provided by

witnesses and established by undertaking appropriate research.

The immediate causes have told us how the accident happened,

whilst the underlying causes will tell us why the accident

happened.

To establish the underlying causes the investigators will need to

ask probing questions of witnesses, primarily to establish their

understanding of the health and safety practices and procedures in

place at this site, and whether they are being implemented and

adhered to. Some of the witnesses the investigator will need to

interview will not have first hand knowledge of the accident that is

being investigated but should be fully aware of the health and

safety practices and procedures of the enterprise

Major writers on accident investigation such as Trevor Kletz,

quoted at the start of this section, all agree that the responsibility

for the basic underlying causes of accidents rests with

management. DuPont, one of the worlds largest enterprises and

manufacturers, espouses, amongst other things, the theory that:

".....all injuries are preventable and are ultimately caused bymanagement failure."

This does not mean that management have deliberately created

situations where a person will be injured, but, usually they have not

fulfilled their duty of care, for example: to provide sufficient safe

working procedures or policies that will identify the hazard before

the risk associated with that hazard becomes unacceptable; or to

provide and enforce sufficient maintenance and replacement

policies to prevent a piece of equipment becoming distorted or

failing.



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Take an example of a person being injured because a rope or

cable used to lift or restrain some load or item, fails, causing the

injured person to be struck by the load or item. The immediate

cause of the accident is that a rope or cable failed. It broke! The

important thing to establish is why did it break. Was there a

procedure in place to regularly check the rope or cable for wear?

Was there a procedure in place to replace the rope or cable after a

pre-described period of time or usage? If not, management have

failed in their duty of care! We all know that ropes and cables are

disposable or consumable items that are subject to wear and tear

and there should have been inspection, maintenance and

replacement procedures in place.

If our research reveals that the inspection, maintenance and

replacement procedures were in place, what do we do? The next

step is to establish were these procedures observed? Did the

person who was responsible for implementing these procedures

know about the procedures and their role? Have they been trained

to assess the conditions of the rope or cable? If not, management

have failed to provide adequate training to ensure that their

employees work in a safe environment!

Our further research indicates the procedures were in place, the

person responsible for implementing the procedures was fullyaware of their responsibilities and had received adequate training

and were competent to carry out the tasks. Ah-ha! The careless

worker! WRONG! Management failure again! Lack of

supervision. It is fine to delegate a responsibility after ascertaining

the delegated person is adequately trained and skilled. However it

is essential that adequate follow up is maintained to ensure these

delegated responsibilities are implemented and continued.

Once again, our research has ruled out all of these factors. The

cable was inspected, maintained and was not due for replacement.What next? Was the rope or cable adequate for the purpose it was

being used? Was the rope or cable for industrial use? Was the

rope or cable quality tested? Was the load excessive? These are

the type of questions that have to be asked, the type of research

that has to be undertaken, in a methodical structured format,

eliminating potential for failure as you go, until you find the root

cause of the accident.



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Hopefully, by now, you will see a trend. All of the scenarios

outlined in the example all ultimately pointed to a management

failure. Failure to have safe working procedures! Failure to have

adequate training for employees! Failure to have adequate

instructions for employees! Failure to have adequate supervision

for employees.

Whilst in some accidents the employee may have done the wrong

thing, and admits it, it still does not absolve management from

having sufficient systems, training, instruction and supervision in

place that should have detected and prevented the employee

doing the wrong thing.

Whilst undertaking the research and analysis of the immediate and

underlying causal factors of this scenario, the investigator should

have been cognisant that they have to make recommendations

and provide preventative strategies as part of their investigations

and reporting, as well as being mindful of the hierarchy of control.

Could the system have been changed to avoid using the rope or

cable? Could the rope or cable be substituted with another method

of restraint or lifting? Was it necessary to restrain or shift this item

or load? Was it necessary for the injured person to be in a position

where they could be struck by the load if the rope or cable failed?

Could a barrier be placed between the load and the location of theinjured person?



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Section 5: REPORTING

An accident report provides a condensed formal record of facts

and recommendations surrounding an accident, giving each level

of management information with which to decide and prioritise

remedial action.

The investigator's memory, like that of a witness, is fragile and will

tend to sub-consciously fill in gaps where no evidence exists: it is a

peculiarity of the human mind. The investigator does have the

advantage of photographs, evidence, exhibits, notes taken at the

time and statements to refer to which will refresh their memory,

however the best approach is to prepare a written report as soonas possible, preferably before they get involved in another

investigation. Remember the old adage:

"The job's not done until the paperwork is finished."

5.1 Preparation of report

When preparing a report the author, in this case the investigator,

must assume the reader does not have any knowledge about theworkplace or the work practices. Indeed they may not have

knowledge of safe work practices. Every aspect will need to be

spelt out, in a concise format, being careful not to become

verbose.

The report, like the investigation, also needs to be a methodical,

systematic, unemotional record of the facts and events that led to

an accident, description of evidence and exhibits collected,

together with an analysis of the causal factors and

recommendations for preventative strategies. Remember there

must be a beneficial outcome for the resources expended on the

investigation.



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The depth of the report, the analysis of the causal factors and

recommendations will be influenced by the seriousness of the

accident, the extent of the injuries received and what type of

investigation is being undertaken, by whom and for what purpose.

An internal investigation will be looking primarily at developing

preventative strategies, whereas an investigation by a statutory

authority will probably be looking at breaches of legislation, and

will be less influenced by the seriousness of the injury but more by

the extent of any breach of legislation.

5.2 Format of report

The report should contain sufficient information to enable a

decision maker to act on the investigator's recommendations. Be

aware that any modification or change to equipment, work

procedures etc., will cost money, consequently cost benefit factors

should be included with recommendations, in an internal

investigation report. The report should commence with a brief

overview of the accident, when, where, what and to whom,

followed by a broader outline of the workplace, the work being

undertaken at the time of the accident and the events leading up to

the accident. These headings will probably be fairly common to all

investigations.

The format of the body of the report will depend on the

circumstances of the accident, and will normally address issues

such as: the qualifications or training of the injured person, the

suitability or condition of any plant or equipment involved in the

event, the contributory influence, actions or failures of other

persons which may have led to the accident and perhaps other

physical factors such as weather, lighting, time of day, length of

work shift, working conditions, housekeeping, etc, which also may

have had some influence, or which can be discounted as havingan influence. For example: The weather was fine with light breezes

and moderate temperature which would have had no influence on

this accident. It is better to make a brief statement like this than to

have the reader wondering if the weather was an influence and if

the investigator overlooked this matter or just failed to comment on

it.



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Photographs and sketches should be strategically located

throughout the text to enable easy reference and access by the

reader. Other relevant documents collected during the

investigation and research phases should be included as

attachments, clearly labelled and included in a contents page as

well as being referenced at the appropriate part in the body of the

report.

The report will conclude with comments or discussion of issues

that have arisen or need to be addressed, the conclusions reached

by the investigator together with appropriate recommendations

including preventative strategies from the investigator. Without this

step the whole investigation and report have been a complete

waste of time.

5.3 Distribution and use of report

The distribution and use of an accident or incident report will

depend on, to some extent, who prepares the report and for what

reason.

At the workplace level, the report is likely to be prepared by a

safety officer or person delegated to manage safety, together witha report from the elected worker health and safety representative

(if any). This report may be a joint report between these two

parties.

The report should be submitted to the enterprise management

through their normal reporting channels, for information and action,

to act on or authorise any recommendations contained within the

report. The report should also be forwarded to the health and

safety committee, if one exists, to form part of the agenda and

discussions for the next scheduled meeting. If the accident was sosevere or the hazards exposed so intolerable, it may be necessary

to convene a special meeting of the health and safety committee to

address the matters raised or recommendations made.



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The health and safety committee is an appropriate forum for

members to discuss the report, the circumstances described in the

report, the outcomes and the recommendations. It may be that the

combined expertise of the committee will provide alternative,

perhaps more practicable solutions or substitutions, to prevent

further occurrences of these circumstances. Pooled resources can

be extremely beneficial, particularly if an enterprise decision maker

is involved in the process. This is also an excellent forum to follow

up and monitor recommendations and preventative strategies, to

ensure they are implemented. When implementation is left to one

person, it is easy for the process to run off the rails if that person is

absent on leave, sick, or leaves the particular work area or the

enterprise. The safety committee will have recorded notes or

minutes to ensure that the recommendations are continuously

reviewed until the matter is satisfactorily completed or resolved.

In the early section of this reading we referred to who conducts an

investigation and further split the options between internal and

external investigators. The external investigators will in most cases

produce a detailed report for the organisation they represent, and if

the person died as a result of the accident, the Coroner will be

seeking a report prepared by a Government agency. If that agency

proceeds to a prosecution for breaches of legislation arising out of

the investigation, a copy will also be forwarded to the CrownSolicitor.



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SUMMARY

Accident investigations are undertaken to establish causal factorsof the event, and the quicker the investigations commences, the

less risk there is of evidence being contaminated and witnesses

descriptions being corrupted. A variety of investigators may be

involved in the investigation of a particular event, and whilst they

may be looking at the event from different perspectives, they all

need to establish the causal factors.

Investigations need to be pre-planned. The investigator should

have all of the tools and equipment that they may require

accessible at short notice, and be prepared to commence aninvestigation immediately. When advised of the circumstances of

an accident they should be considering possible scenarios and

tactics so when they reach the investigation site they have some

concept of what avenue they will be following. The investigation is

a methodical examination of the accident site; the physical

evidence of what happened; the people who have first hand

knowledge of facts, related directly or indirectly to the event; and

any records, papers etc that may contribute to the outcomes of the

investigation.

After this examination has been undertaken and photographs

taken, sketches made, witnesses interviewed and exhibits

collected, there will need to be research into: other similar

accidents; existing work practices and procedures; and other

relevant matters. This research will be necessary to establish the

deeper causal factors. When all of this information is available the

investigator will be able to analyse the event to establish causal

factors, for which they will develop preventative strategies to

reduce the risk of a recurrence of the circumstances surrounding

the event.

At the conclusion of these steps it will be necessary for the

investigator to commit their investigation details and conclusions to

writing, in the form of a report of the event, conclusions reached

and recommendations for preventative strategies. This report

should be submitted to the management of the workplace where

the accident happened, the health and safety committee at the

workplace, and depending on who undertakes the investigation

and for what purpose, the party or parties who commissioned the

investigator's investigation.



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Depending on the status of the investigator, they may or may not

have any part in the implementation of their recommendations.

The implementation and follow up of recommendations will

normally be the role of the management of the enterprise together

with the health and safety committee and elected worker health

and safety representatives of the workplace.

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