Accident Investigation

Summary and Notifications

This program applies to departments at Virginia Tech that wish to take a proactive approach in reducing work-related injuries and illnesses.

For serious incidents, please contact Environmental Health & Safety at 540-231-2341 or 540-231-3600 as soon as possible to ensure that regulatory notifications are made in a timely manner. Types of injuries that must be reported to OSHA and their timeframes can be found on the Emergencies webpage.

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Roles and Responsibilities

General roles and responsibilities for health and safety can be found in university Policy 1005.

Accident/Incident Investigation Program

This program provides a mechanism for supervisors and designated departmental personnel to identify incident causes (from work-related injuries and illnesses) and corrective/preventative actions to prevent future incidents.    

Initial Response

In any serious emergency, the primary concern is to get care for the victim(s) by calling 911. Know the physical address of the emergency, and provide the operator with requested information. Stay on the line with the operator, and do not hang up unless told to do so.

Once help is on the way, and if the scene is safe for you to do so:

• Get the first aid kit and assist the victim following accepted standards of care, if trained to do so (or following instructions from 911 dispatch). Otherwise, help keep the patient calm until emergency services arrive.
• Do not move the victim unless it is absolutely necessary (as identified in First Aid/CPR training).
• Turn off any equipment or power switches that need to be shut down. Do not move anything in the area.
• Make a note of the people present at the time of the incident. This will include any witnesses and the victim's supervisor. Names, phone numbers, and email addresses should be noted.
• Secure the area.  Use barricade tape or lock doors to keep people out of the area until notified otherwise.
• Notify Environmental Health & Safety, your departmental safety Representative, and management of the incident as soon as possible. There may be official notifications that have to be made to Virginia OSHA within hours.
• Make sure an Employer's Accident Report is completed and filed with Human Resources within 24 hours.
  
• Begin your investigation.

Site Conditions

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.

Photos

Take photos of the site from all angles, as well as up close and from a distance.

• Take photos of the general area.
• Take close-up photos 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.

Drawings/Sketches

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. 

Witness Statements

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.

Investigation Process

Identifying Contributing and Root Cause(s)

After gathering 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.

Corrective and Preventative Action(s)

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 Prevenative Action 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.

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Accident/Incident Investigation Kit

Preparing a kit of necessary forms and tools will help you be more effective once your investigation begins. Keep the kit where it is easily accessed. Suggested kit contents:

• Accident investigation forms
  • Notification Record
  • Incident Statements
  • Interview questions
  •  Graph paper
  • Paper/note pad
• Barricade tape
• Camera
• Flashlight
• Pens/pencils
• Rubber gloves
• Sample bags or containers with labels
• Tape measure
• Personal protective equipment
  • Safety glasses
  • Hearing protection
  • Gloves
  • Steel-toed shoes (dependent upon location)
  • Hard hat (dependent upon location)
  • Coveralls

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Reporting to OSHA; OSHA citations

Virginia OSHA (VOSH) requires that fatalities, in-patient hospitalizations, amputations, or loss of an eye be reported within certain time frames. Environmental Health & Safety coordinates OSHA reporting for the university. Response for incidents and accidents is available at Emergencies.

Virginia Tech can also be cited by VOSH for safety and health violations. It is important for the department to work with EHS to isolate any hazardous conditions immediately, abate the hazard once the investigation has been completed, and document actions taken as part of the official response to any potential citations.

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Accident Prevention

Accident prevention is a proactive measure taken by the department to eliminate hazards, where possible, utilize engineering and administrative controls to reduce the risk, and/or require the use of personal protective equipment in order to minimize the extent of injury. Here are some actions to take:

• Get employees involved in accident prevention. Be proactive by encouraging employees to correct hazardous conditions that they observe, or promptly report the situation to a supervisor for coordination of response.
• Conduct regular health and safety meetings with employees on related topics. Education, instruction, training, and enforcement of procedures minimize the human factors that contribute to incidences. Safety meetings give the department an opportunity to address areas needing improvement, keep safety at the forefront of daily activities, and provide the employees an opportunity to report or discuss situations that may need to be addressed.
• Ensure that supervisors lead by example. It is difficult to get employees to act in a safe manner when they observe supervisors ignoring the rules or asking employees to take shortcuts.
• Conduct periodic self-inspections of the work area. Supervisors or designated departmental safety representatives should routinely inspect the work area and employee activities to identify potentially unsafe conditions which need to be corrected. A self-inspection checklist is available for your convenience.  It may also be tailored to meet a department’s specific industry or focus.
• Conduct a Hazard Assessment of the work area to identify hazards inherent to the work area or job tasks and establish appropriate controls for elimination or reduction. Environmental Health & Safety offers additional training for conducting a hazard assessment, hazard monitoring, consultation, and job task review.
• Have an Emergency Action Plan for your department and inform employees of its contents.  If a plan has not already been developed, use the template provided.
• Establish required training for personnel. 

Definitions

Accident: The occurrence in a sequence of events that produces unintended injury, death, or property damage (refers to the event, not the result of the event). Note: “Accident” and “incident” are used interchangeably in this program.

Causal factors: All of the events or conditions that contributed to the occurrence of the accident. Also see “contributing cause(s).”

Contributing cause(s): All of the events or conditions that contributed to the occurrence of the accident. Also see “causal factors.”

Corrective action: that action which would have prevented the accident from occurring.

Incident: An undesired event that may cause personal harm or other damage. Note: “Accident” and “incident” are used interchangeably in this program.

Near miss incident: An injury requiring first aid; the newly discovered unsafe condition; fires of any size, or nontrivial incidents of damage to equipment, building, property, or product.

Preventative action: That action which will prevent the accident from occurring to other personnel in the same or similar situation.

Root cause: The event, that had it not occurred, would have prevented the incident.

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Contact Information

Robin McCall-Miller, Occupational Safety Program Manager

Phone: 540-231-2341
Email: rmmiller@vt.edu