Accident Investigation

Accident/Incident Investigation Quick Links

Accident/Incident Investigation Program

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. Environmental Health & Safety may identify departments or work groups with high numbers of worker's compensation claims for which an accident investigation program must be implemented.

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.

Environmental, Health & Safety may request a copy of departmental accident investigations, and reports may be shared with  regulatory agencies and/or worker's compensation representatives upon request. Accident investigation reports should be presented to departmental management upon completion, and corrective/preventative actions taken to improve the department's safety program should be documented.

Roles and Responsibilities

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.    

The Occupational Safety and Health Act (OSHA) requires that employees be furnished a place of employment free from recognized hazards that are causing, or are likely to cause, death or serious physical harm. As a state agency, we are also mandated by Executive Order 94 (05) to:

• Evaluate work-related injuries/illnesses to determine how to prevent or reduce the injuries.
• Establish goals to reduce serious occupational injuries and illnesses to enhance worker safety.
• Involve agency employees in identifying workplace hazards and establishing goals to eliminate or reduce them.

Application

Environmental Health & Safety will conduct accident or near miss investigations which resulted in (or may have resulted in) serious injury or death.  Departments with a defined safety position should conduct internal accident investigations for minor incidents. Accidents involving contractor personnel should be investigated by the contractor. Environmental, Health and Safety may serve as liaison to external regulatory agencies investigating an accident, and serve as a point-of-contact for information exchange.

Scope

All incidents should be investigated, regardless of the severity of injury or amount of property damage; however, the extent of the investigation will depend on the outcome, or potential outcome, of the incident.

• All serious injuries or illnesses must be investigated. Typically, Environmental Health & Safety leads this investigation in conjunction with the department.
• All minor or near miss incidences resulting in a significant number of worker's compensation claims being filed (e.g. trends) should be investigated on a departmental level, which may include collaboration with Environmental Health & Safety. 
• Minor or near-miss incidents requiring only first aid or minor property damage will not be investigated as thoroughly as incidents where medical treatment is required or property damage is extensive unless the potential outcome could have resulted in a disabling injury or death.

Initial Response

General information for initial emergency response is provided.

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. 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. 

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.

Identifying Contributing and Root Causes

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 Actions

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.

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

Investigating Near Misses

A near miss incident is an injury requiring first aid; a newly discovered unsafe condition; fires of any size; or nontrivial incidents of damage to equipment, building, property, or product. While near misses do not necessarily need to be investigated, if the near miss happens to be one of the top causes of incidents in your area, or if the near miss could have resulted in a serious injury, it should be investigated to reduce the likelihood that the next occurrance will result in an injury.

Notification record

The Notification Record Form can be used to initiate the accident investigation process and document related information that will be needed moving forward.

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. Any violation cited must be abated within the specified period, or contested. Environmental Health & Safety coordinates OSHA reporting for the university. Contact Robin Miller at 540-231-2341 or rmmiller@vt.edu for assistance as soon as the incident occurs so that proper procedures and notifications can be coordinated.

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.

Accident Prevention

There are many actions a department can take to reduce the likelihood of an accident occurring. Be proactive with these tips.

Definitions

Definitions related to accident investigation.

Contact Information

Robin McCall-Miller, Occupational Safety Program Manager

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