Accident Reporting & Investigation Paul Craythorne Health, Safety & Environmental Advisor.

Accident Reporting & Investigation

Paul Craythorne

Health, Safety & Environmental Advisor

Accident Reporting & Investigation Course Objectives

to understand: accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation

Accident Reporting & Investigation Common Uninformed Comments

accidents just happen we don’t have many accidents safety is expensive the insurance will pay safety is just common sense

Accident Reporting & Investigation Accident Definition

what is an accident? unplanned & uncontrolled event

that led to, or could have led to:• injury to persons, damage to

property/plant/equipment, impairment to the environment or some other loss to the company

Accident Reporting & Investigation Accident Definition

accident types• minor dangerous occurrence• near miss• plant/equipment damage• minor injury• lost time injury• disablement/fatality


Accident Definition

Frank Bird (Accident Triangle)• 600 near misses• 30 property damage• 10 minor injuries• 1 serious injury (lost time or fatal)


Accident Causation

environment personal fault unsafe act unsafe condition accident injury/damage


Accident Causation

causal factors• individual• job• organisation


Accident Causation

causal factors• individual

– knowledge

– skills

– training

– experience

– personality

– attitude

– risk perception


Accident Causation

causal factors• job

– task– workload– equipment– controls– procedures– environment


Accident Causation

causal factors• organisation

– culture– leadership– resources– work patterns– communications


Accident Causation

Kings Cross Fire (1987) - 31died• discarded cigarette• accumulation of rubbish• poor cleaning regime• wooden escalator• failure of fire fighting equipment• lack of emergency training• poor safety culture


Accident Causation

Herald of Free Enterprise (1987) - 189 died

• failure to close bow doors• no checking/reporting system• commercial pressures• internal friction• disease of sloppiness


Accident Causation

Clapham Junction (1988) - 35 died & 500 injured

• signal failure• incorrect maintenance• degradation of working practices• training problems• communication problems• poor supervision• excessive working hours• failure to learn lessons


Accident Causation

Piper Alpha (1988) - 167 died• maintenance error• inexperience• poor maintenance procedures• communications breakdown• permit to work system fault• safety procedures not practised


Accident Causation

Automotive Supplier (1999) - 1 died• poor safety culture• lack of guarding• lack of training• poor perception of risk• no safe systems of work• no risk assessment programme• no effective accident system• no communication


Accident Costs

insured costs uninsured costs


Accident Prevention

reasons• humane• economic• legal


Accident Prevention

control measures• safety procedures/work instructions

• adequate training

• effective communications

• good housekeeping

• guards/safety devices/warning signs

• adequate working environment

• regular safety inspections

• risk assessment


Accident Reporting/Notification

• internal report form• HSE RIDDOR report• injury claim requirement


Accident Investigation

reasons• identify root causes• identify faults• identify corrective/preventative action• prevent recurrence



investigation team• supervisor• safety rep• engineer• manager• safety officer



investigation objectives• establish chain of events• identify root causes• identify faults• identify corrective/preventative action



investigation techniques• attend promptly

• ensure medical attention

• leave scene undisturbed

• take photographs/sketches

• take measurements

• take samples

• gather documentation

• interview witnesses



investigation techniques• interviewing witnesses

– explain purpose

– their version of events

– do not listen to ‘hear say’

– ask open questions

– avoiding leading or implying

– do not apportion blame

– express appreciation



investigation report• identify team• summarise consequential events• identify root causes• describe other weaknesses• identify corrective/preventative action• allocate responsibility & timescale

Accident Reporting & Investigation Paul Craythorne Health, Safety & Environmental Advisor.

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