Accident Investigation

University policy 1005 requires that departments maintain safe and healthy living, learning, and working environments for faculty, staff, students, and visitors to our campus. Incidences should be investigated to determine corrective and preventative action(s). 

• Departments must ensure that all work-related injuries and illnesses, regardless of whether the employee sought medical attention, are reported to Human Resources via the Employer’s Accident Report.
• Each department should require that all persons with supervisory responsibilities and designated safety representatives attend Environmental Health & Safety Accident Investigation training.

Departmental designated safety representatives should:

• Work with Environmental Health & Safety as necessary to investigate accidents that are serious in nature to identify causes and help implement corrective/preventative action(s).
• Review accident data for the department to identify trends, and investigate accidents to identify causes and implement preventative action(s).
• Communicate departmental accident data to supervisory and management personnel periodically (i.e. quarterly, semi-annually, or annually).
• Coordinate corrective/preventative action(s) with departmental supervisory and management personnel, as necessary.
• Respond to corrective action requests issued by Environmental Health & Safety.

Supervisors are responsible for:

• Investigating accidents that are minor in nature or frequent in occurrence (i.e. trends) to identify causes and implement corrective/preventative action(s).
• Assisting departmental safety representatives and/or Environmental Health & Safety with accident investigations for all serious injuries/illnesses occurring within your area of responsibility, or where your personnel was involved either directly or indirectly (e.g. a witness to the incident).
• Responding to corrective action requests issued by Environmental Health & Safety.

Employees involved in a work-related injury or experiencing a work-related illness must:

• Report the injury or illness to their supervisor immediately.
• Ensure that an Employer's Accident Report has been completed for worker's compensation purposes.
• Cooperate with university personnel involved in the investigation.

Environmental, Health & Safety will provide technical support, accident investigation training, and oversight for this program; however, involvement by Environmental, Health & Safety does not relieve the departments, supervisors, or contractors of their individual responsibilities. Environmental Health & Safety's responsibilities for this program include:

• Developing, implementing, and administering the program.
• Training on all aspects of the program requirements and maintaining centralized records.
• Serving as a technical resource.
• Conducting accident investigations for incidents that are serious in nature, involve a fatality or other injury where notification to OSHA is required, involve contractors, or which may be of special interest (i.e. trends, high rates of incidents).
• Serving as liaison with external agencies, such as Virginia Occupational Safety and Health (VOSH) or worker's compensation representatives, during their investigations.

Contractors must comply with all local, state, and federal safety requirements, and must assure that all employees performing work on Virginia Tech property have been suitably trained and are provided appropriate personal protective equipment per the Safety Requirements for Contractors and Subcontractors program. Contractors should notify Environmental Health & Safety of any incident involving serious injury where OSHA may investigate. Environmental Health & Safety may investigate any incident involving contractors and Virginia Tech personnel or the public. Corrective and/or preventative action recommendations will be communicated to the contractor and Virginia Tech project manager.

Each investigation should be conducted as soon after the incident as possible. A delay of only a few hours may permit important evidence to be destroyed or removed either intentionally or unintentionally. Before objects are moved, cleaned, or removed, the investigator should record the scene of the incident as it was at the time of the accident. This will involve taking pictures of the site from all angles, as well as up close and from a distance. Be sure to take close-ups of any detail which may be important, such as tools, machinery, work area conditions, site orientation, control panel positions, work flow patterns, etc. It may be helpful to place an object, such as a ruler or pencil, of known size into the picture to show proportion. Be sure you know how to use the camera beforehand; learning to use it during a critical incident may cost you valuable evidence. If possible, make sure the date and time stamp feature is turned on for investigative purposes.

It may be necessary to make a sketch of the area layout for future reference, or building floor plans may be available. Use a tape measure to note the actual distances between objects for exact reference. Remember to include vertical measurements as well as horizontal. Check the entire area (ceiling, walls, equipment, and floor) for signs of damage or disturbance, or which may in any way be related to the incident. 

If the injured person is available to make a statement, events leading up to the accident and a description of exactly what happened, should be documented.  Identify any witnesses to the accident, and obtain a written statement from them as well. Identify the supervisor/principal investigator or other person in charge and obtain a written statement. This should happen as soon as possible after the incident while details are still fresh in their minds. Ask general, open-ended questions, such as who, what, when, where, why, and how. Ask the person being interviewed what they think caused the accident, and what they think needs to happen to correct the situation. The Incident Statement form is used to record witness, supervisor, and the injured employee accounts. 

Once statements have been obtained, they should be reviewed to establish a sequence of events and a timeline, if necessary. They will also provide information for you to being formulating specific questions to ask during a follow up interview if sufficient detail is not provided, or if certain details are unclear.  Interviews may involve hazard-specific questions that need clarification, such as was the person wearing appropriate personal protective equipment? Was there a standard operating procedure for the task that was being performed? Is there an operator/owner's manual available for the machinery/equipment involved?

Information to be gathered should include who, what, when, where, and how in sufficient detail so that you have a very good understanding of the accident and anything or anyone who may have been involved in some manner. Now review the evidence for deviations from standard conditions or protocols. This may include reviewing the following documentation:

• Training records;
• Accident history for the area/first aid reports;
• Standard operating procedures or safe work practices;
• Owner's or operator's manuals and manufacturer instructions;
• Departmental policies;
• Health and safety programs; and
• Safety-related documentation, such as Hazard Assessment Forms, Energy Control Procedures, Confined Space Assessment Forms, scaffold inspections, etc.

Now that you've gathered all of your information and data, it's time to review and analyze it to determine "why" the accident occurred (i.e. the root cause).  One easy-to-use tool for identifying contributing causes to an accident, and to help identify the root cause, is the Guide for Identifying Causal Factors and Corrective Actions. It is relatively self-explanatory, and provides common corrective actions to consider.  Simply go through the list of quesions in the "Causal Factors" column and identify all possible contributing causes. It breaks the areas to review into equipment, environment, people, and management. Anything identified here should be further investigated to help determine the root cause. 

It is generally accepted now that there may be more than one root cause. On the Corrective and Preventative Actions Form, you should include any and all causes that are to be acted upon.

Depending on the situation, there may only be one corrective action identified to address the root cause, or there may be several corrective actions that need to be taken.  A corrective action will address the immediate incident to ensure that it does not happen again to the person involved. For example, John Doe, who was injured during a fall from an upper level, may need to take fall protection training to ensure he is aware of requirements and expectations for using a personal fall arrest system. Or, the unguarded edge of a retaining wall should be temporarily marked off limits with barricade tape or fencing to keep all personnel from being exposed to the hazard.

Preventative actions may also be identified on a broader scale, such as installing a guardrail system along the unguarded edge to provide permanent protection for all personnel in the area. Perhaps safety training should be required for additional personnel who may also be exposed to the hazard, or there are engineering controls which would eliminate exposure to a hazard.

The Corrective and Preventative Actions Form can be used to track actions to be completed. This form may need to be reviewed periodically to ensure progress and completed action items are documented. Once all action items have been completed, the accident investigation can be considered closed.