Accident investigation procedure

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This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at https://www.dir.ca.gov/od_pub/disclaimer.html. Subchapter 7. General Industry Safety Orders Group 18. Explosives and Pyrotechnics Article 113. Explosives and Pyrotechnics Return to index New query ## §5248. Blasting Accident Reports and Procedures. (a) In the event of a blasting accident or unusual occurrence affecting the safety of employees in which explosive materials are involved, whether or not personal injury is sustained, the employer shall within 24 hours forward a report of the incident to the Division. (b) The report shall state: (1) The names and license numbers of all blasters involved. (2) The names and occupations of any employees injured. (3) The type of explosive materials, detonator, and method or methods of detonation of explosive materials. (4) A factual account of events pertinent to the accident. (c) In any blasting incident in which serious personal injury is sustained, there shall be no continuation of the blasting operation involved until such time as the Division has completed its investigation or authorized resumption of work. ## NOTE Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code. ## HISTORY 1. New section filed 7-11-2003; operative 8-10-2003 (Register 2003, No. 28). Go Back to Article 113 Table of Contents

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# Causation Models (cont.) ## Why should recommendations be made? (cont.) For example, you have determined that a blind corner contributed to an incident. Rather than just recommending "eliminate blind corners" it would be better to suggest: - install mirrors at the northwest corner of building X (specific to this incident) - install mirrors at blind corners where required throughout the worksite (general) Never make recommendations about disciplining a person or persons who may have been at fault. This action would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future investigations. In the unlikely event that you have not been able to determine the causes of an incident with complete certainty, you probably still have uncovered weaknesses within the process, or management system. It is appropriate that recommendations be made to correct these deficiencies. ## The Written Report The prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams. Identify clearly where evidence is based on certain facts, witness accounts, or on the team's assumptions. If doubt exists about any particular part of the event, say so. The reasons for your conclusions should be stated and followed by your recommendations. Do not include extra material that is not required for a full understanding of the incident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good report is quality, not quantity. Always communicate your findings and recommendations with workers, supervisors and management. Present your information 'in context' so everyone understands how the incident occurred and the actions needed to put in place to prevent it f…

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# NCDOL investigates Crane Accident ## Investigation Process What triggers an investigation by the N.C. Department of Labor's Occupational Safety and Health Division? • A worker's death. - Hospitalization of an employee, an amputation or the loss of an eye. • The department may also receive information of a fatality or catastrophe from media reports or referrals from other government agencies. ## How is the NCDOL OSH Division notified? • An employer must notify NCDOL within eight hours of any work-related fatality. In-patient hospitalizations of one or more employees, any work-related amputation, and any work-related loss of an eye must be reported within 24 hours. ## What will the investigation focus on? The investigation will usually be limited to the events surrounding the accident unless observations at the site indicate a broader investigation is needed. ## What will happen during the investigation? - An OSH investigator will go to the accident site and collect physical evidence, including photographs. - The investigator will interview employees, witnesses and management officials about the accident to deter- mine its cause. • Any violations of safety and health standards will be noted and citations will be issued. ## How long will the investigation take? An investigation can take anywhere from a few weeks to six months, depending on the complexity of the accident. ## When are investigation results disclosed? - Citations and penalties, if issued, can be released to the public on the issuance date. • Other contents of the file cannot be released until the case is closed or final order on citations is rendered. ## The Investigation While nationwide tower crane accidents have been in the news, most of the crane-related injuries and deaths in North Carolina involve mobile type cranes such as crawler cranes and truck cranes. When investigating crane accidents, OSH investigators will seek to determine several factors, including whether: . Crane o…

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# Causation Models (cont.) ## Physical Evidence (cont.) - noise levels - time of day You may want to take photographs before anything is moved, both of the general area and specific items. A later study of the pictures may reveal conditions or observations that were missed initially. Sketches of the scene based on measurements taken may also help in later analysis and will clarify any written reports. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the scene should be prepared. ## Witness Accounts Although there may be occasions when you are unable to do so, every effort should be made to interview witnesses. In some situations witnesses may be your primary source of information because you may be called upon to investigate an incident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator. Witnesses should be kept apart and interviewed as soon as possible after the incident. If witnesses have an opportunity to discuss the event among themselves, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts. Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene where it is easier to establish the positions of each person involved and to obtain a description of the events. On the other hand, it may be preferable to carry out interviews in a quiet office where there will be fewer distractions. The decision may depend in part on the nature of the incident and the mental state of the witnesses. ## Interviewing The purpose of the interview is to establish an understanding with the witness and…

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# Incident Investigation (cont.) ## Why look for the root cause? (cont.) - Was a safe work procedure being followed? If not, why not? - Were safety devices in order? If not, why not? - Was the worker trained? If not, why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction. ## What are the steps involved in investigating an incident? First: - Report the incident occurrence to a designated person within the organization. - Provide first aid and medical care to injured person(s) and prevent further injuries or damage. The incident investigation team would perform the following general steps: - Scene management and scene assessment (secure the scene, make sure it is safe for investigators to do their job). - Witness management (provide support, limit interaction with other witnesses, interview). - Investigate the incident, collect data. - Analyze the data, identify the root causes. - Report the findings and recommendations. The organization would then: - Develop a plan for corrective action. - Implement the plan. - Evaluate the effectiveness of the corrective action. - Make changes for continual improvement. As little time as possible should be lost between the moment of an incident and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera or recording device, tape measure, etc.) should be immediately available so that no time is wasted. What should be looked at as the cause of an incident? Incident Investigation CCOHS

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# Causation Models (cont.) ## Management (cont.) This model of incident investigation provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place some of the sample questions in different categories; however, the categories are not important, as long as each question is asked. Obviously there is considerable overlap between categories; this overlap reflects the situation in real life. Again it should be emphasized that the above sample questions do not make up a complete checklist, but are examples only. ## How are the facts collected? The steps in the investigation are simple: the investigators gather data, analyze it, determine their findings, and make recommendations. Although the procedures are seemingly straightforward, each step can have its pitfalls. As mentioned above, an open mind is necessary in an investigation: preconceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be made until all the data is gathered. ## Physical Evidence Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. In some jurisdictions, an incident site must not be disturbed without approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as: - positions of injured workers - equipment being used - products being used - safety devices in use - position of appropriate guards - position of controls of machinery - damage to equipment …

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# Causation Models (cont.) ## Interviewing (cont.) Data can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past incident reports, safe-work procedures, and training reports. Any relevant information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar incidents. ## What should I know when making the analysis and recommendations? At this stage of the investigation most of the facts about what happened and how it happened should be known. This data gathering has taken considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question - why did it happen? Keep an open mind to all possibilities and look for all pertinent facts. There may still be gaps in your understanding of the sequence of events that resulted in the incident. You may need to re-interview some witnesses or look for other data to fill these gaps in your knowledge. When your analysis is complete, write down a step-by-step account of what happened (the team's conclusions) working back from the moment of the incident, listing all possible causes at each step. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if: - it is supported by evidence - the evidence is direct (physical or documentary) or based on eyewitness accounts, or - the evidence is based on assumption. This list serves as a final check on discrepancies that should be explained. ## Why should recommendations be made? The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents. Recommendations should: - be specific - be constructive - identify root causes - identify contributing factors Resist the temptation to make only general recommendations to save time and effort. …

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# Causation Models (cont.) ## What should be done if the investigation reveals human error? (cont.) Failing to point out human failings that contributed to an incident will not only downgrade the quality of the investigation, it will also allow future incidents to happen from similar causes because they have not been addressed. However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures. ## How should follow-up be done? Management is responsible for acting on the recommendations in the investigation report. The health and safety committee or representative, if present, can monitor the progress of these actions. Follow-up actions include: - Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not). - Develop a timetable for corrective actions. - Monitor that the scheduled actions have been completed. - Check the condition of injured worker(s). - Educate and train other workers at risk. - Re-orient worker(s) on their return to work. Fact sheet last revised: 2019-11-26 ## Disclaimer Although every effort is made to ensure the accuracy, currency and completeness of the information, CCOHS does not guarantee, warrant, represent or undertake that the information provided is correct, accurate or current. CCOHS is not liable for any loss, claim, or demand arising directly or indirectly from any use or reliance upon the information. Incident Investigation CCOHS

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# NCDOL investigates Confined Space Accident ## Investigation Process What triggers an investigation by the N.C. Department of Labor's Occupational Safety and Health Division? • A worker's death. - Hospitalization of an employee, an amputation or the loss of an eye. • The department may also receive information of a fatal- ity or catastrophe from media reports or referrals from other government agencies. ## How is the NCDOL OSH Division notified? • An employer must notify NCDOL within eight hours of any work-related fatality. In-patient hospitalizations of one or more employees, any work-related amputation, and any work-related loss of an eye must be reported within 24 hours. ## What will the investigation focus on? The investigation will usually be limited to the events surrounding the accident unless observations at the site indicate a broader investigation is needed. ## What will happen during the investigation? - An OSH investigator will go to the accident site and collect physical evidence, including photographs. - The investigator will interview employees, witnesses and management officials about the accident to deter- mine its cause. • Any violations of safety and health standards will be noted and citations will be issued. ## How long will the investigation take? • An investigation can take anywhere from a few weeks to six months, depending on the complexity of the accident. ## When are investigation results disclosed? • Citations and penalties, if issued, can be released to the public on the issuance date. • Other contents of the file cannot be released until the case is closed or final order on citations is rendered. NCDOL N.C. Department of Labor Josh [redacted identifier], Commissioner N.C. Department of Labor Occupational Safety and Health Division 1101 Mail Service Center Raleigh, NC [redacted identifier] www.labor.nc.gov 1-800-NC-LABOR Standards: General Industry - 1910.146: Permit- Required Confined Spaces Construction Industry …

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# Incident Investigation (cont.) ## What is an incident and why should it be investigated? (cont.) The information that follows is intended to be a general guide for employers, supervisors, health and safety committee members, or members of an incident investigation team. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event. Reasons to investigate a workplace incident include: - most importantly, to find out the cause of incidents and to prevent similar incidents in the future - to fulfill any legal requirements - to determine the cost of an incident - to determine compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.) - to process workers' compensation claims The same principles apply to an inquiry of a minor incident and to the more formal investigation of a serious event. Most importantly, these steps can be used to investigate any situation (e.g., where no incident has occurred yet) as a way to prevent an incident. ## Who should do the investigating? Ideally, an investigation would be conducted by someone or a group of people who are: - experienced in incident causation models, - experienced in investigative techniques, - knowledgeable of any legal or organizational requirements, - knowledgeable in occupational health and safety fundamentals, - knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation, - able to use interview and other person-to-person techniques effectively (such as mediation or conflict resolution), knowledgeable of requirements for documents, records, and data collection; and - able to analyze the data gathered to determine findings and reach recommendat…