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Health and Safety Guide


 

SECTION A2: ACCIDENT INVESTIGATION PROCEDURE


Introduction

Accidents occur when hazards escape detection during preventive measures, such as a job or process safety analysis, when hazards are not obvious, or as the result of combinations of circumstances that were difficult to foresee. A thorough accident investigation may identify previously overlooked physical, environmental, adminstrative, or process hazards, the need for new or more extensive safety training, or unsafe work practices. The primary focus of any accident investigation should be the determination of the facts surrounding the incident and the lessons that can be learned to prevent future similar occurrences.

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Scope and Application

All accidents should be investigated. The depth and complexity of the investigation will vary with the circumstances and seriousness of the accident. The Supervisor or other individual responsible for operations involved in an accident should ensure that an investigation is conducted and that when appropriate, corrective actions are taken.

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Program Description

The first priority whenever an accident occurs is to deal with the emergency and ensure that any injuries or illnesses receive prompt medical attention. The accident investigation should begin immediately thereafter. This ensures that details of what occurred will be fresh in peopleís minds and that witnesses donít influence one another by talking about the accident. It also minimizes the likelihood that important evidence is not moved, lost, taken, destroyed, or thrown away before the scene has been thoroughly inspected.

Types of Accidents

Accidents fall into two categories, serious and non-serious. Non-serious accidents do not cause lost workdays even though the worst that could happen did happen. Examples of these include paper cuts, minor scratches or abrasions, or system failures that have minor consequences, such as a low-pressure hose that ruptures and sprays cool water. Serious accidents include both those which did involve lost workdays and those which might have. This second type of serious accident is called a "near miss." Examples of near misses with serious injury potential include:

  • A worker twists an ankle in a fall from a low scaffold (this could easily have been a broken leg or worse);
  • A worker tips back in a chair and topples backward (backward falls are always serious because head injury might result);
  • A worker turns on a machine and gets a slight shock (shock from voltage potential greater than 75 volts DC or 40 volts AC is considered serious).

After an accident or near miss occurs, supervisors should contact EHS. All serious accidents, those involving lost workdays or near misses, should be investigated with the same thoroughness.

Who Should Investigate

Supervisors should note initial details of the incident and contact EHS to schedule an interview with the injured employee. Regardless of the type of investigation, the supervisor should be involved for the following reasons:

  • Supervisors have a responsibility to provide their workers with a safe and healthful workplace;
  • Supervisors know the workers and their work better than anyone else and are in the best position to gather the facts and find a practical solution to the problem;
  • The supervisorís involvement can help promote better relations with workers by demonstrating concern for their safety and attention to accident prevention.


Accident Investigate Approach

As with most other tasks, skill in conducting effective accident investigations improves with experience. A good basic approach is to find out what caused the accident and what can be done to prevent or minimize the chances of a similar accident occurring. Some suggestions that may help supervisors get the facts and reach a conclusion include:

  • Maintain objectivity throughout the investigation. Its purpose is to find the cause of the accident, not to assign blame for its occurrence.
  • Check the accident site and circumstances thoroughly before anything is changed.
  • Discuss the accident with the injured person, but only after first aid or medical treatment has been given (see Section A1, Work-Related Injuries and Illnesses). Also talk with anyone who witnessed the accident and those familiar with conditions immediately before and after it occurred.
  • Be thorough. Small details may point to the real cause.
  • Reconstruct the events that resulted in the accident, considering all possible causes. Determine unsafe conditions or actions that separately or in combination were contributing factors.


What To Do With The Results

Supervisors should take action to control or eliminate the conditions that caused the accident once these have been conclusively identified. EHS can provide assistance in determining the level of action that may be necessary, such as the following:

  • When equipment changes or safeguards are necessary, supervisors should discuss specific recommendations with Department management;
  • When an operation can be changed to eliminate the hazard, supervisors should make the change if it is within their authority, or seek the necessary approval from Department management;
  • If unsafe acts by workers are involved, ensure that the worker is properly trained and that training is followed. All others involved in similar operations should be trained as well.

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Roles and Responsibilities

Department

  • Ensure accidents involving their operations or workers are investigated.
  • Ensure corrective actions are taken.

Supervisors

  • Particpate in incident investigations.
  • Take corrective actions.

EHS

  • Investigate incidents promptly and thoroughly.
  • Issue accident investigation reports.
  • Provide training in investigation methods and techniques when requested.

Individual

  • Cooperate with supervisors and others during investigations.

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