Accident Investigation

The purpose of an accident/incident investigation includes;

• it is a legal requirement
• it helps to establish the root causation; and
• provides grounds to implement hazard controls to prevent re-occurrences

An accident is an undesired event that results in physical harm to a person or damage to property.An incident is an undesired event that could (or does) downgrade the efficiency of the business operation or, if the circumstances had been different, it may have resulted in an accident.

It should always be considered practical to conduct an accident investigation for all accidents and incidents however legislation indicates that only accidents that result in a critical injury or death need to be investigated. The members of a committee who represent workers shall designate one or more such members to investigate cases where a worker is killed or critically injured in the workplace. Committee members may inspect the actual place where the accident occurred and any machine, device or thing that may be associated with the event, and shall report his or her findings to a Director at the Ministry of Labour, and to the committee.

If the worker member conducting the investigation is not familiar with the area in which the accident occurred, they can request assistance from a competent individual to complete the investigation. Requesting the assistance of a qualified and license tradesperson is an excellent example of a competent individual.

In order to determine if a critical injury has occurred and for the purposes of the Act and regulations, critically injured means an injury of a serious nature that;

• places life in jeopardy
• produces unconsciousness, even for a moment
• results in substantial loss of blood, a little as 500 ml
• involves the fracture of a leg or arm, but not a finger or toe
• involves the amputation of a leg, arm, hand or foot, but not a finger or a toe
• consists of burns to a major portion of the body, a little as 10%; and
• loss of sight in one eye

Secure and Manage the Accident Scene

The first priority after medical aid is provided is to ensure the accident scene is secured and managed. In the event of a critical injury or fatality, persons at the workplace must have permission from the attending Ministry of Labour Inspector before the scene can be entered or altered.

The committee must not disturb, destroy, alter or carry away any wreckage, article or thing from a scene where a critical injury or death occurs except for the purpose of;

1. saving life or relieving human suffering
2. maintaining an essential public utility service or a public transportation system; or
3. preventing unnecessary damage to equipment or other property

Notice of Death or Injury

The Act states that where a person is killed or critically injured from any cause at a workplace the employer must immediately notify a Ministry of Labour Inspector, and the JHSC and trade union (if any) by written notice. The employer shall, within forty-eight hours after the occurrence, send to a Director a written report of the circumstances of the occurrence containing such information and particulars as the regulations prescribe.

Notice of Accident, Explosion or Fire Causing Injury

If a person is disabled from performing his or her usual work or requires medical attention because of an accident, explosion or fire at a workplace, but no person dies or is critically injured because of that occurrence, the employer shall, within four days of the occurrence, give written notice of the occurrence to the following;

• the joint health and safety committee
• a health and safety representative and the trade union, if any; and
• the Ministry of Labour Director (if an inspector requires notification of the Director)

Notice of Occupational Illness

If an employer is advised by, or on behalf of a worker, that the worker has an occupational illness or that a claim in respect of an occupational illness has been filed with the Workplace Safety and Insurance Board, the employer shall give notice in writing, within four days of being so advised;

1. to a Director
2. to the J.H.S.C.; or
3. a health and safety representative and to the trade union, if any

Documenting the Accident Scene

Written notes, tape recordings, photographs, test results or any other documentation that can help identify root causation are very important to note as they may be introduced into the court of law.

Who is involved in the accident scene?

• identify the individuals involved in the scene including witness(s), complainant(s) and others involved
• record the individuals full name, home address and telephone numbers, the department where they work, and the name of their immediate supervisor

Where did the accident happen?

•  describe the specific location where the accident took place including taking pictures of the area, and including a schematic drawing, etc

When did the accident happen?

• Day/Month/Year
• Time of report
• Time of the incident include the shift (if applicable)
• Environmental conditions such as weather, lighting conditions, noise at the time of the event and air temperature

What actually happened?

• list a chronological sequence of events
• include observations by witnesses, and the person conducting the investigation; what do you think happened
• include the actions that the investigator took

How did it happen?

• report the facts as you see them, listing each item in a logical sequence

Interviewing the Witnesses

It is very important that committee members control their own emotions during this time in order to provide a supportive environment for the witnesses. When conducting interviews it is critical that the witness does not perceive the process as pointing out blame, but rather than a step in a process of identifying the reasons why the accident happened.  Witness need to understand that by learning what happened and way, we can find alternate processes, implement new policies or revise existing programs, in an effort to avoid a re-occurrence. 

Workers are expected to provide information and assistance as required to a committee member during an accident investigation. A worker must not interfere or knowingly provide false information.

The following list explains are a few important steps in the interviewing process;

• separate each witness so that individual recollection is not tainted by another person’s thoughts
• put the witness at ease by assuring no blame
• ask the witness to recall events from what they heard, seen, and felt
• ask open-ended questions to help generate discussion
• do not lead the witness during questioning and ensure they come to their own conclusions
•  repeat or reword the question if necessary to ensure clarity
•  ask the witness for suggestions to prevent re-occurrence; and
•  encourage further contact and thank the witness

Analysis and Conclusions

Once the accident has been investigated, all documentations must be analyzed in order to draw conclusions to determine the contributing factors, immediate causes, and root causes.

Contributing factors could include;

•  lighting, weather, noise, time of day
•  language barriers; or
•  personal issues

Immediate causes could include;

• struck by, caught by, caught between, fall to lower level
• fall on same level, overexertion, exposed to
• operating at improper speed
• failure to secure
• removing safety devices; or
• failure to use PPE

Root causes can fall into two categories:

Personal Factors

•  lack of knowledge, skill, fatigue; and
• stress & improper motivation

Job System Factors

•  inadequate maintenance
•  inadequate leadership & supervision
•  inadequate work standards; or
•  inadequate purchasing

Recommendations and Follow-up

After an accident investigation is completed, the committee must decide a course of action whether they introduce a hazard control, or revise an existing control, something must be done to prevent a re-occurrence.

Once the written recommendation is received by the employer, they have a legal obligation to respond within twenty-one days with either an action plan for corrective actions, or the reasons why the recommendation for corrective action will not be considered.

With any recommendation or implementation of a hazard control, there should be a follow-up to ensure that a response was received by the employer or in the case where controls have been installed, that the controls are being evaluated to determine practicality and effectiveness.