A Practical Guide to Effective Workplace Accident Investigation

Preface Acknowledgements About the Author PART ONE INTRODUCTION TO ACCIDENT INVESTIGATION Chapter 1 Introduction 1.1 Objective 1.2 Workplace Injury and Death Statistics 1.3 Concepts Explained 1.4 Safety 1.5 Proactive Safety versus Reactive Safety 1.6 Occupational Hygiene
1.7 Accident 1.8 Injury 1.9 Injury versus Accident 1.10 Injury Severity Luck Factor 1.11 Unintended Loss 1.12 Accident versus Incident 1.13 Hazard Identification and Risk Assessment (HIRA)
1.14 Hierarchy of Control 1.15 Safety Management System (SMS) Controls 1.16 Accident Causation 1.17 Accident Immediate Causes 1.18 Accident Root Causes 1.19 Accident and Near Miss Incident Investigation 1.20 Conclusion
Chapter 2 The Philosophy of Safety 2.1 Workplace Health and Safety 2.2 Management Function 2.3Safety Authority, Responsibility and Accountability 2.4 Management Leadership
2.5 Upstream Health and Safety Management Systems (SMS) 2.6  Pre-contact 2.7 Contact 2.8 Post Contact 2.9 Accident Ratio 2.10 Near Miss Incidents 2.11 Interruptions
2.12 Legal Requirements 2.13 Lessons Learned Chapter 3 Accidental Loss Causation Theories 3.1 Accident Causation 3.2 Traditional Cop-outs
3.3 Accidents are Complex Events 3.4 No Single Cause 3.5 Domino Accident Sequence 3.6 Accident Causation Theories 3.7 Heinrich's Domino Accident Sequence 3.8 Frank E. Bird’s Updated Domino Accident Sequence
3.9 NOSA’s Updated Domino Accident Sequence 3.10 The Human Factors Theory 3.11 The Epidemiological Theory  3.12 The Systems Theory
3.13 Functional Resonance Accident Model (FRAM)  3.14 The Combination Theory  3.15 Multiple Causation Theory 3.16 Single Event Theory 3.17 The Petersen’s Accident / Incident Theory
3.18 Energy Release Theory  3.19 Swiss Cheese Model 3.20 The Symptoms versus Causes Theory 3.21 The Pure Chance Theory 3.22 Cause, Effect and Control of Accidental Loss
3.23 Accident Proneness Theory 3.24 Purpose of Accident Investigation 3.25 Investigation Following the Logical Sequence Accident Investigation Method
3.26 Root Causes Analysis 3.27 Remedial Measures 3.28 Summary Chapter 4 Traditional Accident Investigation 4.1 Who Messed Up? 4.2 Punitive Actions 4.3 The Safety Fear Factor
4.4 Fact Finding and not Fault-Finding  4.5 Cover-ups 4.6 Cop-outs 4.7 Why Accidents and Near Miss Incidents are not Reported 4.8 Historic Restraints 4.9 Paradigms 4.10 Safety Culture 4.11 Summary
Chapter 5 The Politics of Accident Investigations 5.1 Stumbling Block 5.2 Opening a Can of Worms 5.3 Blame Game  5.4 Looking Good 5.5 Measures of a Safe Workplace
5.6 Safety Records 5.7 Legal Action 5.8 Shifting the Responsibility 5.9 Results of Conflicting Interests 5.10 Fixing the Problem, not the Person 5.11 Conclusion
PART TWO  ACCIDENT INVESTIGATION METHODOLOGY Chapter 6 Objective of Accident Investigation 6.1 A Systematic Review 6.2 Legal Requirement 6.3 Safety Culture
6.4 What Occurred? 6.5 Events 6.6 Timeline 6.7 Evidence 6.8 System Failure 6.9 Worker Failure 6.10 Fixing the Workplace, Not the Worker! 6.11 Fix the Problem 6.12 Following up
6.13 Conclusion Chapter 7 Nominated Accident Investigators 7.1 Management’s Responsibility 7.2 A Joint Approach 7.3 Management Training 7.4 External Experts
7.5 Health and Safety Representatives 7.6 Potential for Loss 7.7 Investigation Committee 7.8 Experience 7.9 Knowledge 7.10 Management Skills  7.11 Guidelines 7.12 Investigators must be Competent!
7.13 Conclusion Chapter 8 Problem-solving Methods 8.1 Basic Problem-solving Steps 8.2 The Fishbone Diagram Method 8.3 Fault Tree Analysis 8.4 The Why Method
8.5 Who, What, When, How, Where and Why? 8.6 The Five Step Problem-solving Technique 8.7 The Brainstorming Method 8.8 Problem-solving Skills 8.9 Conclusion  Chapter 9 Rules of Accident Investigation
9.1 Objective  9.2 Do Fact-finding – Not Fault-finding! 9.3 Delve Deeper  9.4 Look at Both Sides of the Coin 9.5 More Information 9.6 Face Value  9.7 Witnesses 9.8 Prejudge
9.9 Jumping to Conclusions 9.10 Potential for Loss 9.11 Look Beyond the Injured Person 9.12 Perception of Others 9.13 Communication Skills 9.14 Factual Information
9.15 Rumors 9.16 Time 9.17 Conclusion Chapter 10 Designing an Accident Investigation Report Form 10.1 A Guide 10.2 Check Boxes 10.3 Type of Event 10.4 Injury Severity
10.5 General Information 10.6 Damage 10.7 Description 10.8 Energy Exchanges 10.9 Photos 10.10 Costing 10.11 Risk Assessment 10.12 Immediate Accident Causes 10.13 Root Causes
10.14 Personal Protective Equipment (PPE) 10.15 Witnesses 10.16 Remedies (Control Measures) 10.17 Follow up 10.18 Signatures 10.19 Investigation Close Off 10.20 Conclusion
Chapter 11 Accident Site Inspection 11.1 The Starting Point 11.2 Securing the Site 11.3 Investigators’ Caution 11.4 Source of Information 11.5 Gathering Evidence
11.6 Environmental Conditions 11.7 Photos and Sketches 11.8 Diagrams 11.9 People 11.10 Documented Evidence 11.11 Site Revisited 11.12 Workplace Standards 11.13 Conclusion
Chapter 12 Interview Guidelines and Interviewing Techniques 12.1 Introduction 12.2 Interview versus Interrogation 12.3 Suitable Location 12.4 Interview Guidelines
12.5 Types of Witnesses 12.6 Victims 12.7 Colleagues 12.8 Experts 12.9 Question Techniques 12.10 Accident Reconstruction 12.11 Conclusion Chapter 13 Documentation Review
13.1 Introduction 13.2 Standards 13.3 Procedures 13.4 Training 13.5 Policies 13.6 Audit Reports 13.7 Inspection Reports 13.8 Maintenance Records 13.9 Past Experience
13.10 Past Events 13.11 Near Miss Incidents 13.12 Witness Statements 13.13 Incident Recall 13.14 Conclusion PART THREE  INVESTIGATING AND ANALYZING THE EVENT Chapter 14 The Logical Sequence Accident Investigation Method (Cause, Effect and Control)
14.1 Introduction 14.2 The Domino Effect 14.3 A Basic Loss Causation (Accident) Sequence 14.4 The Logical Sequence Accident Investigation Method 14.5 Remedial Risk Control Measures
14.6 Conclusion Chapter 15 Determining the Losses 15.1 Using the Logical Sequence Accident Investigation Method 15.2 Logical Starting Point 15.3 Risk Assessment 15.4 Losses
15.5 Types of Losses 15.6 Direct Losses (Insured Losses) 15.7 Injury Classifications 15.8 Indirect Losses (Uninsured Losses) 15.9 Totally Hidden Losses 15.10 Conclusion Chapter 16 Identifying the Exposures, Impacts and Energy Exchanges 16.1 Cause of Loss 16.2 Agency
16.3 Agency Part 16.4 Exposure, Impact or Energy Exchange, Terminology 16.5 Common Classifications of Injury Causing Exposures or Impacts  16.6 Fatal Statistics
16.7 Conclusion Chapter 17 Immediate Cause Analysis – High-risk Behaviors (Unsafe Acts) 17.1 Introduction 17.2 Human Failure 17.3 Other Failures 17.4 Errors  17.5 Other Types of Errors
17.6 Error Chain 17.7 Categories of High-risk Behaviors (Unsafe Acts) 17.8 Immediate Cause Analysis – High-risk Behavior Chapter 18 Immediate Cause Analysis – High-risk Conditions (Unsafe Conditions)
18.1 Hazards 18.2 Hazard Modes 18.3 Hazard versus Risk  18.4 Hazard Ranking 18.5 High-risk Workplace Conditions (Unsafe Conditions)
18.6 Safety Management System Standards 18.7 Categories of High-Risk Workplace Conditions 18.8 Conclusion Chapter 19 Root Cause Analysis – Personal (Human) Factors
19.1 Introduction 19.2 Precursors to Immediate Causes of Accidents 19.3 Root Causes of Accidents 19.4 Root Cause Analysis 19.5 Personal (Human) Factors
19.6 Inadequate Physical Capability 19.7 Inadequate Mental (Cognitive) Capability 19.8 Lack of Knowledge 19.9 Health and Safety Training 19.10 Lack of Skill
19.11 Stress, Depression and Anxiety 19.12 Improper Motivation 19.13 Conclusion Chapter 20 Root Cause Analysis – Job (Organizational, Engineering or Workplace) Factors
20.1 Introduction 20.2 Precursors to Accident Immediate Causes 20.3 Root Causes of Accidents 20.4 Root Cause Analysis 20.5 Root Cause Analysis – Job (Organizational, Engineering or Workplace) Factors
20.6 Inadequate Leadership or Supervision 20.7 Inadequate Engineering or Design 20.8 Example of a SMS Standard for Purchasing Specifications 20.9 Inadequate Purchasing 
20.10 Inadequate Maintenance 20.11 Inadequate Tools or Equipment 20.12 Inadequate Work Standards 20.13 Inadequate Ergonomic Design 20.14 Wear and Tear 20.15 Abuse or Misuse
20.16 Conclusion Chapter 21 Safety Management System (SMS) Controls 21.1 ntroduction 21.2 Management 21.3 Safety Authority, Responsibility and Accountability
21.4 Management Leadership 21.5 Four Basic Functions of Management 21.6 Safety Planning 21.7 Safety Organizing 21.8 Safety Leading 21.9 Safety Controlling
21.10 Conclusion PART FOUR  REMEDIAL MEASURES TO PREVENT A RECURRENCE Chapter 22 Failure to Identify Hazards and Manage Risks 22.1 Introduction 22.2 Hazard Identification and Risk Assessment (HIRA)
22.3 The Purpose of HIRA 22.4 Sources of Hazards and Hazard Burden 22.5 Hazard Identification and Risk Assessment (HIRA) Objective  22.6 Types of Workplace Hazards
22.7 Hazard Identification and Risk Assessment (HIRA) Process 22.8 Safety Management System (SMS) Control Elements (Programs) 22.9 Accident Causation  22.10 Safety Management System (SMS) Controls
22.11 Conclusion Chapter 23 Risk Control Remedial Measures to Prevent Accident Recurrences 23.1 Objective of Health and Safety in the Workplace 23.2 Management’s Responsibility
23.3 Employees’ Responsibility 23.4 Accidents are Indicators 23.5 Hierarchy of Control 23.6 Accident Remedial Measures (Risk Control) 23.7 Cost Benefit Analysis
23.8 Root Causes Eliminated 23.9 Safe Management of Change (Change Management) 23.10 An Employee Job Specification Program (SMS Element) 23.11 Workplace Ergonomic Program (SMS Element)
23.12 Significant Part of an Accident Investigation 23.13 Management Action Plan 23.14 Conclusion Chapter 24 Action Plan for Risk Control Remedial Measures
24.1 Action Plan Method 24.2 Requirements of an Action Plan 24.3 Cost Benefit Analysis 24.4 Conclusion PART FIVE EVALUATING THE QUALITY OF ACCIDENT INVESTIGATION REPORTS
Chapter 25 Evaluating the Quality of Accident Investigation Reports 25.1 Introduction 25.2 Measurement 25.3 Scoring the Accident Investigation Report Form
25.4 Has the Accident Investigation been Effective? PART SIX ACCIDENT SCENARIOS Chapter 26 Accident Scenario One – Boxcor Manufacturing 26.1 Introduction
26.2 Investigating the Accident  26.3 Exposure, Impacts and Energy Exchanges 26.4 High-risk Behaviors 26.5 Root Cause Analysis – High-risk Behavior
26.7 High-risk Workplace Conditions 26.8 Root Cause Analysis – High-risk Workplace Conditions  26.9 Inadequate Management Control 26.10 Risk Control Remedial Measures to Prevent a Recurrence
26.11 Conclusion Chapter 27 Accident Scenario Two – Overhead Electrical Line Accident 27.1 Introduction 27.2 Background 27.3 Site Inspection 27.4 Change of Digging Method
27.5 Investigating the Accident  27.6 Exposure, Impacts and Energy Exchanges 27.7 High-risk Behaviors 27.8  Root Cause Analysis – High-risk Behavior 27.9 High-risk Workplace Conditions
27.10 Root Cause Analysis – High-risk Workplace Conditions 27.11 Risk Control Remedial Measures to Prevent a Recurrence 27.12 Conclusion
PART SEVEN CONCLUSION Chapter 28 Fixing the Workplace, not the Worker 28.1 Missed Opportunities 28.2 Fixing the Workplace, not the Worker 28.3 Paradigm Shift 28.4 A Can of Worms 28.5 The Logical Sequence Accident Investigation Method
28.6 Conclusion – Investigators Beware References

Biography

Ron C. McKinnon, CSP (1999–2016), is an internationally experienced and acknowledged safety professional, author, motivator, and presenter. He has been extensively involved in safety research concerning the cause, effect, and control of accidental loss, near-miss incident reporting, accident investigation, safety promotion, and the implementation of health and safety management systems for the last 46 years.

The author received a National Diploma in Technical Teaching from the Pretoria College for Advanced Technical Education, a Diploma in Safety Management from the Technikon SA, South Africa, and a Management Development Diploma (MDP) from the University of South Africa, in Pretoria. He received a Master’s Degree in Health and Safety Engineering from the Columbia Southern University.

From 1973 to 1994, Ron C. McKinnon worked at the National Occupational Safety Association of South Africa (NOSA), in various capacities, including General Manager of Operations and then General Manager Marketing. He is experienced in the implementation of health and safety management systems (SMS), auditing, near-miss incident and accident investigation, and safety culture change interventions.

From 1995 to 1999, Ron C. McKinnon was a safety consultant and safety advisor to Magma Copper and BHP Copper North America, respectively. In 2001, Ron spent two years in Zambia introducing the world’s best safety practices to the copper mining industry. After leaving Zambia, he was recruited to assist in the implementation of the world’s best class safety management system at ALBA in the Kingdom of Bahrain.

After spending two years in Hawaii at the Gemini Observatory, he returned to South Africa. Thereafter, he contracted as the Principal Health and Safety Consultant to Saudi Electricity Company (SEC), Riyadh, Saudi Arabia, to implement a world’s best practice safety management system, throughout its operations across the Kingdom involving 33,000 employees, 27,000 contractors, 9 consultants, and 70 Safety Engineers.