Accident Investigation
Mike Wisherop, CIH, CSP
LLNL, Hazards Control
Deputy Team Leader
925-423-1746
ISM
Lawrence Livermore National Laboratory
Why Are Accidents Investigated? 2
To prevent similar accidents from occurring
(learn a lesson)
Investigations are required by Cal/OSHA (IIPP).
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
What Accidents Get Investigated? 3
All accidents resulting in injury or illness to
employees.
Other accidents that should be investigated:
– injury or illness to non-employees
– property damage
– near misses
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Who Investigates Accidents? 4
Supervisors should be the lead investigators
Safety professionals should provide assistance
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
When are Accidents Investigated? 5
Immediately
Worry about Workers’ Comp forms later.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
What Factors are Important? 6
Severity of injury or illness
Tool, equipment, or product used
Location of the accident
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
How are Accidents Investigated? 7
Some accidents can be investigated just by
interviewing the injured employee.
Others require inspection of the accident site.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
How are Accidents Investigated? 8
Site inspections:
Inspect the site as soon as possible.
Secure the accident scene with
barricade tape.
Take pictures or draw a sketch.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
How are Accidents Investigated? 9
Conduct interviews
The injured employee
Witnesses
Interview as soon as possible
Ask open-ended questions
Be neutral
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
How are Accidents Investigated? 10
Compare interview data to observations at the
accident scene.
Piece together what happened and how it happened.
List all contributing factors .
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
What are the contributing factors? 11
Usually a combination of elements lead to an accident:
Unsafe Acts
Unsafe Conditions
Uncontrollable Events
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Dig Deeper (why, why, why?) 12
What contributed to the unsafe act or condition?
No clear policy or procedure?
No enforcement?
In a hurry?
Previous work created an unsafe condition?
Lack of training?
Distraction - Unfamiliar job location?
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Finally 13
List corrective actions
Share the entire investigation report with those who
have similar exposures.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Accident Simulation 14
What steps do you take?
1. Care for Ted
– Call 911
– Send another employee to the hospital with Ted to relay
information about Ted’s condition
– Check in periodically
– Notify Ted’s emergency contact at home
– Ask someone to barricade the area with chairs or tape while
you care for Ted
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Accident Simulation 15
2. Isolate the accident scene
3. Report the injury to EH&S (equivalent)
4. Interview Witnesses
– Ask open-ended questions (Example: What did you see?)
– Remain neutral (not assigning blame)
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Accident Simulation 16
5. Look for clues at the accident scene
– Which equipment, tools, or items were being used when the
accident occurred?
– Is anything out of place or knocked over?
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Accident Simulation 17
5. List all the factors that contributed to the injury
6. List controls that will be implemented to prevent a
recurrence
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Safety Basis Calculation Process 18
What were the contributing factors?
– Ted used the wrong type of equipment.
– No understood work rule against using a rolling swivel chair.
– The step ladder was unsafe.
» Continued…
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Safety Basis Calculation Process 19
What were the contributing factors?
– Inspection and/or reporting unsafe condition process did not
work.
– The broken ladder should have been taken out of service
and replaced.
– Building maintenance worker was not asked to set the clock.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Safety Basis Calculation Process 20
What controls can be implemented to prevent
recurrence?
– Establish a work rule prohibiting the use of furniture as a
ladder or step stool.
– Repair or replace the stepladder.
– Establish an equipment safety inspection and reporting
procedure.
» continued
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
Safety Basis Calculation Process 21
What controls can be implemented to prevent
recurrence?
– Determine if the building maintenance worker will set the
clocks. Consider using this service.
– Share any lessons learned with others in the department.
ISM Lawrence Livermore National Laboratory
CA EH&S Academy 2007
The End
ISM
Lawrence Livermore National Laboratory
