Investigation of accidents

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1. Introduction

2. Why investigate accidents

3. Definitions

4. Attitude of workers

6. Procedures for investigation

7. Interview witnesses and the injured

8. Records

9. Consequences of accidents

10. Causes of accidents

11. Factors accidents

12. Classification of the types of accidents

13. Domino sequence

14. Conclusions

1. Introduction

In general all companies one way or another core activities are performed to avoid accidents. At least you have ideas of how to move materials, care in the use of the various areas of work, know the importance of order and cleanliness of the workplace, is careful not to cause fires, caution with electricity, some talks or supervisory councils, some even work process or deliver catalogs, etc..

Other companies in this field is an integral part of daily work in them are talks of five minutes daily, for each critical work is done working procedures are performed accident and incident investigations, statistics are kept, are made weekly or monthly meetings, etc..

However, experience teaches us that although we try to avoid, however accidents occur at work. Typically, the risk prevention measures have long-term positive effects. So, even with the best prevention plan or operational risk control, we will see some accidents affecting workers to the equipment or the environment.

At these times we will see how the supervisor in charge of the worker or the work area is presented in place and starts asking questions.

* What to do

* What attitude should be adopted

* Why research

* What conclusion must reach the investigator

Answering these questions is to answer the other question can I use the accident investigation And who is responsible for investigating

and if you do not know how to investigate and get to the real cause advises Who

2. Why investigate accidents

Whenever a place is an accident, we must remember that there is a problem that led to this. This problem exists because:

1. – Unknown right way to do things.

2. – No deficiencies are corrected

3. – Not inspect or assess the working conditions and the risk is underestimated

4. – Someone without authorization or without experience decided to go ahead, despite the deficiency

5. – Someone in authority decided that the cost to correct the deficiency, exceeded the benefit derived from the correction.

6. – Someone in authority did not listen to the worker when he reported the deficiency.

Any incident, accident or process defect must be reported for investigation and the employee must cooperate to transform the negative fact, in a security action or opportunity to improve.

Similarly, the supervisor is required to listen to worker input, analyze the information provided and make a decision to improve the process.

3. definitions

Discussing the topic in question, let’s define some terms associated with it.

Accident Investigation

Preventative is a technique to detect and control the causes of the accident, in order to avoid repeating the same or similar to one already happened.

Objective is to assess all the facts, opinions, statements or information related, as an action plan to solve the problem that gave rise to the deficiency.

Purpose of the investigation

The fundamental purpose of investigating accidents is:

Discover the causes that led to the accident to clear. When investigating an accident should be able to establish as accurately as possible and acts which were sub standard conditions that allowed the accident to happen.


Undesired event that results in losses for personal injury, damage to equipment, materials and / or the environment. Generally involves contact with a power source whose power exceeds the capacity limit of the human body resistance of the structures.

ECHO’s all unexpected that interrupts a normal process that can produce injury or damage. Need not be injuries in an accident, it suffices that only one interruption exists. Furthermore, this is unexpected interruption.

Substandard Act

Any deviation in the performance of individuals in relation to established standards, to keep up the continuity of operations and a minimum level of losses, is considered an abnormal act that imposes risk and directly threatens the security of the system or respective process. An act is detected substandard observations.

Substandard condition

Any change or variation introduced to the physical characteristics or operation of equipment, materials and / or the work environment and involving abnormality in terms of the standards established or accepted, are conditions of risk that can lead directly to operational accidents . A condition is detected substandard inspections.

Having clarified this fundamental point, we can clarify questions before us if the supervisor asks something like witnessing an accident, being part of the accident or participating as a researcher of the same.

4. Attitude of workers

It is important that workers know that he should participate in the work of accident prevention, as it depends heavily on operational risk control.

All materials or equipment may be unsafe if the person moves, it does not in the correct, safe, or do not know how.

If the worker is suffering the pain of the injury, if the worker who suffers the consequences of the accident, then it is he who must implement security standards, which has instructed his supervisor or advisor risk prevention .

As we know that research is reaching the causes of the accident to clear, the only attitude we can take is to cooperate with the investigation, giving the maximum possible details. With that we will be collaborating effectively to the prevention of accidents, because if we eliminate the causes found, we can prevent recurrence.

If an accident, however slight repeated, does not ensure that the result of repetition is the same as before. What once was light, to be repeated not only serious, but can even be fatal. No one can say the consequences of an accident, and the only thing left is to try to avoid a repeat. Hence the importance of a good accident investigation.

Reporting accidents

Workers generally do not report or accident report, primarily because:

1. – They fear disciplinary action

2. – Concern about the report

3. – Concern about reputation

4. – Fear of treatment Medic

5. – Antipathy to medical staff

6. – Desire to avoid work stoppage

7. – Desire to keep your resume clean

8. – Poor understanding of the importance of informing them.

9. – Lack of motivation to get involved.

Normally companies are established by the Internal Rules of Order, Health and Safety, the obligatory reporting minor accidents they may be.

This requirement reflects the provisions of labor legislation and the need for preventive research and analyze the facts, to take preventive action.

5. Responsible for research

The person responsible for doing the research is the supervisor of the line. But because he and not the safety officer, for example

The reasons for the investigation to be made by the supervisor are:

a. – The, is best known both work and workers.

b. – is responsible for the safety of its people

c. – It’s who must implement corrective action and therefore it must be satisfied.

For these reasons, the supervisor should do research in addition to this, shows its commitment to work with the company and with the same.

Work Security Advisor or Prevencionista Risk, will be to assist the supervisor in research and to provide you with the means to fulfill it.

Once found the reasons for the accident, the supervisor will be required to use all means at its disposal to eliminate those causes.

6. Procedures for investigation

We must remember that this is an investigation like any other. therefore, we have to answer the same

questions we try to answer all research. But, what is the best way to do research

We must answer the following questions:

1. – Who is the injured

2. – Where did the accident

3. – When the accident occurred

4. – How was the accident

5. – Why was the accident

6. – Who were the witnesses of the accident

1. – Who is the injured

Normally it is thought that this question is easy to answer. However, the question requires a complete picture of the situation. It is not only to know the name and age of the injured person, but also his years in the company and the experience you have at work, in which he crashed.

Many times it happens that people are injured experienced at work who had never had occasion to do in the company.

Therefore it is also know who is the head of the person responsible at the time that crashed. It usually happens that the responsible supervisor at that time than the usual supervisor or because the person was doing that job.

2. – Where did the accident

Answering this question means having a detailed picture of the exact spot where the accident occurred. Many supervisors are satisfied with general descriptions, such as:

Garage Company or patio of the winery

When asked what are descriptions to help clarify the accident. In the cases mentioned, maybe the descriptions should be: lube pit, left empty storage drums, right lane access to the garage, south gate of the workshop.

3. – When the accident occurred

Now the question is not only the exact time at which the accident occurred. Answer the question means knowing the source of the accident, that is, the person performing the work at the time that crashed. The ideal is to get here also detail the stage of the person performing work. This will further clarify the acts easily and substandard conditions that contributed to the accident occurred.

4. – How was the accident

In answering this question we are placing the time the accident took place. We must consider how the person made contact with his environment. If that environment was something to the person or if the person moved toward the object of the environment, if the injury was caused by the force of the contact or if there was no strength in him.

Of course, in order to give a good answer also need to know is the injury of the victim and the relationship between her and the object that produced it.

5. – Why was the accident

The last question addresses the causes of the accident. We see her acts and substandard conditions that contributed to the accident took place, to personal and work factors. It is normal to submit two types of causes in accidents. Both must be fully clarified in order to effectively manage future corrective action.

It should be clear that the acts and substandard conditions have in turn causes, and we get to eliminate those causes if we are to effectively control the risks that cause accidents. Behind substandard acts are personal factors behind substandard conditions are the causes or factors of labor origin, and both must direct our prevention efforts.

Not doing so means leaving open the causes for repeated acts and substandard conditions and, ultimately, accidents.

6. – What were the causes

You can not terminate an investigation if it has reached the bottom of it, these are clearly determine what were the causes of the accident. Accidents do not happen by chance nor by accident casualty.

Speaking of causes is meant to plant something or someone that causes the accident. They can be:

a. – Action substandard, produced by the worker, for example powering a machine in repair.

b. – substandard condition produced by the work environment, such machinery in disrepair

Principle of accident causation

Accidents happen because there are causes that provoke

These causes can be identified and eliminated or controlled.

7. – Who were the witnesses of the accident

Witnesses are also the source of the accident. To answer the questions, the supervisor should use all sources of information available to them.

These sources are:

a. – The interview witnesses and the injured.

b. – The study of the crash site

c. – The study of the equipment and tools involved.

d. – Reconstitution of the accident

Generally the three first means is achieved in most cases clarify details of the accident. Only if doubts remain, the supervisor must turn to the fourth source, taking care not to repeat the act or substandard condition that resulted in the accident.

Never should interview witnesses together, and hopefully not discuss the accident between them before the interview, for any changes in the statement.

7. Interview witnesses and the injured

Of all the possible media, which present major problems, interview witnesses and the injured from the accident. The problems that arise are human relations, as in the development of an interview, the supervisor must convince the worker, how valuable is your support for accident investigation and that the investigation was not guilty of the accident is looking but knowing the causes of the accident to clear.

Recommended schedule an interview

1. – Remember workers the purpose of the research

Remember you are not looking to punish anyone guilty or that the sole aim and effort is to the causes of the accident to clear.

2. – Request an account as possible of objective facts

When the person is doing the story, not interrupt for any reason. Nor take written notes, as this only leads to nervousness of the person. Take mental note and save any questions for when the person has finished his story.

3. – Ask questions that complement the story

After the exposure of workers to verify any questions that have been submitted. Ask tactful, listening version of the person and not the version put itself at the mouth of the other person. Remember also that we are all very objective and remember seeing only what we need. Try then, reaching the maximum possible objectivity.

4. – Check if the researcher knew what happened

After doubts clarified, the interviewer has heard the version that the necessary correction and asks if there has been some misunderstanding. It helps to remember without taking notes.

5. – Discuss with the interviewee possible means to prevent recurrence.

The latter is done with two objectives:

a. Strengthen the initial objective of the research, which is aimed at eliminating the causes.

b. Greater involvement and employee motivation through discussion.

Study of the crash site

In doing so, the supervisor must locate the position that the person had before the accident and that was after it. You should see the moves which were each made before, during and after the accident. You must find the conditions that made the accident.

For all this requires that the place is not fixed after the accident. Any such arrangement must wait as long as possible, the realization of the investigation.

Study of equipment and / or materials involved

The equipment and / or materials may be part of the crime scene, as in the study of the crash site, now try to see if any equipment condition contributed to the accident. It may be a defect in design or maintenance, as it can happen that there were defects in its operation.

Almost always these three sources will be sufficient to get a clear picture of how the accident occurred and the causes that provoked it.

When researching

The accident investigation should be done as quickly as possible. This is not always possible, but in that case the supervisor should try to do it soon. In no case leave it until later, mainly for two reasons:

1. – The earlier you do the research, fewer things will be moved from the crash site.

2. – While the memories are fresher, more objective versions will deliver witnesses. The more time passes, the greater the influence of feelings about memories.

What kind of accidents should be investigated

They should investigate all accidents, even those that have not resulted in injury or damage. However, you need to be practical and start investigating the accidents that have occurred more serious injuries or damage larger.

+ For more serious injuries, we understand every accident that has caused a loss of no less than one day. In other words the employee is absent from work for one business day.

+ For larger damage, we must understand any accident that paralyzed halting production team.

As we move through the action of risk prevention or control of operational risk in the business, we must go one step further in the investigation of accidents that impair production processes, causing losses to the company. When prevention programs and risk control are in place, we also investigate accidents have been minor or no lost time accidents, the latter sometimes called incidents.

The investigation of these accidents is necessary because many times can lead to more serious accidents, if repeated. Accidents might call “minor” accidents are notices “major”.

8. Records

All research should be recorded on a form specially prepared for this. Besides statistical records must be separated, carrying a complete classification of accidents by:

Part 1

a. – Name of injured or damaged equipment identification

b. – Age, experience, or position of the injured

c. – Supervisor or injured

d. – A place in which the event

e. – Length of time in service the same team and distributor.

f. – Date and time of event

Part 2

a. – Source of the accident

b. – Type of Accident

c. – Agent accident

d. – injury Agent

e. – Type of injury (diagnosis)

f. – Causes of the accident (substandard conditions and actions)

Part 3

* Specify the precise causes of the fact

* Determine what steps must be taken to prevent recurrence of the accident

* Analysis of the accident, immediate corrective action taken and measures to be taken in the future.

Part 4

Research by:

Copies sent to:

Principles of humanity

It may happen that a supervisor, to understand the importance of accident investigation, make every effort to do my best. Also tend to be the kind of supervisor that prioritizes production over the terrain.

However, there are principles that everyone should remember and give ultimate meaning to both security and the investigation of accidents, are reminiscent of humanitarian principles in the ultimate goal of prevention, is the human being, the worker primarily as a person.

Principles should not miss:

1. – First is the care for the injured, if there was one accident consequences.

2. – Respect people must always take both actions to take, such as how to take them.

No research is important enough to go on to lead one of these two principles.

9. Consequences of accidents

The injury to workers is just one of the possible consequences of accidents. It turns out that the accident is an unexpected event that causes losses, and as such has some other consequences foreseen and others not. Even some of these losses can be insured.


Waste of time


Damage to equipment and / or materials, tools

Damage to the environment


Others not listed

The consequences of accidents can be injuries, damages, losses, etc. We say “can be and are not”, because there may be an accident without causing these consequences. As stated earlier accidents have causes and are not produced by chance, but the result is the same azaristica, ie for example when a parachutist jumps from a plane in a jump from 2000 to 3000 meters high and is not parachute opens, as a result of this accident should have a fatal outcome, but not always.

Another common example would be that when a person slips by stepping on a banana peel, should feel pain for a while and no consequence, but there are people who have died in the same accident.

The way that an accident can have one or more different results in every situation, so the result is azaristica.

For example in a traffic accident occurring at least the following consequences: disabling injuries and minor damage to cars and equipment, loss of time, injury to persons outside the accident, relatives psychological harm, loss given default delivery or arrival in a business or delivery of documents, increase in insurance premiums, etc..

Consequence for workers

Workers suffer consequences that are at least:

a. – self-doubt. He who once crashed may be pending if lifting injury again and be afraid, to return to the same place in that crashed.

b. – Disorder of family life. The person who is injured often annoying to feel that they can work at home. Psychological harm family members suffer painful look bedridden.

c. – Disorganization of activities outside the home. You can not attend meetings with friends, play sports or recreation.

d. – Reduction of income. While insurance covers most of the expenses, the person does not have the same income.

Consequences for the company

Accidents also cause losses to the company such as overtime payments to replace the injured worker, decreased productivity and that no worker can do the job the same way that the owner of that worker activity, lack of encouragement and low morale of other workers, waste of time for all workers attend to injured or comment on the accident between them, etc..

Cost of Accidents

To give a graphic idea of what really mean accidents as costs for society, can be represented as an iceberg (iceberg). The top, which is in view, the costs would be covered by the company with the insurance obligation, also called direct costs. The lower mass of the iceberg that is not much bigger, would be under the surface and are called indirect costs.

This has first seems exaggerated, not so much because accidents really are a much bigger problem than it appears on the surface.

$ 1: Costs insured (Doctors, offsets)

$ 5 to 50: Costs uninsured accounts (Damage to the building materials and the product, damage to equipment and tools, interruptions and delays in production)

$ 1 to 3: Costs uninsured unposted (Recruit and train staff, replacements, research, etc.

Figure 1: Cost Iceberg

A comprehensive analysis of the costs of damage to property around the world, made by Frank Bird Jr. and Frank Fernandez, has led them to accept the fact that the cost of property damage uninsured is 5 to 50 times greater than the insured costs of injuries and compensation, while other sectors are uninsured 1 to 5 times above compensation costs and medical expenses.

10. Causes of accidents

So far we have considered the fact of the accident and the consequences, mainly from the human side. However, from the point of view of prevention, which is what we want, we must wonder about the causes of accidents. We have said, that accidents had well-defined causes and that these causes can be identified and eliminated or controlled.

There are two major causes of accidents, people and the working environment.

Workers will cause accidents when performing actions or work with substandard.

The working environment will cause accidents when substandard conditions exist.

It is normal in an accident we find not only one but several causes acting at the same time, we can plot as follows:

Actions substandard


Substandard conditions

Human causes of accidents

A human causes of accidents have called the substandard actions. In general, substandard actions are defined as any action (things done) or inaction (things not do) that can lead to an accident. It undue personal performance, which deviates from the procedures or working methods accepted as correct, whether written or delivered in the form of verbal instruction by supervision. Common stock is, many times we do not think that these can lead us to an accident.

Examples of substandard actions

* Failure to follow work procedures

* Working without authorization or may not be able

* Do not use personal protective equipment

* Teasing

* Driving at excessive speed.

* Smoking in the presence of combustible or flammable

Every action has an explanation substandard. There is something that leads a person to commit that action. In that something must be primarily preventive action. A factor that explains the actions we call substandard personal factor.

Personal factors can be divided into three main types:

1. – Lack of knowledge (not known)

2. – Lack of motivation or improper attitude. (Not)

3. – Lack of physical or mental ability (can not)

Lack of knowledge

Lack of knowledge or skill occurs when the wrong person is selected to run for office, the worker is not adequate, you have not been taught or have not practiced enough.

Generally it happens that a supervisor sends a worker to perform an activity without asking if you know or do not, or not

make certain that actually knows the work assigned.

Lack of motivation

Improper attitudes occur when the person tries to save time, to prevent efforts to avoid discomfort or to win a prestigious misunderstood. In short, when his attitude toward his own safety and that of others is not positive.


The physical or mental impairment occurs when the wrong person is selected to run for office, the worker is not appropriate, the person has been diminished physical or mental capacity.

Control of these personal factors can be done with recruitment, training, medical checks and other good management practices.

Environmental cause of the accident

A environmental causes of accidents have called the substandard conditions. In general, substandard conditions are defined as any condition of the work environment that may contribute to an accident. These conditions of the work environment is comprised of the physical space, tools, structures, equipment and materials in general, do not meet the minimum requirements to ensure the protection of people and physical resources work.

Examples of substandard conditions

* Power lines ungrounded

* Floor slippery or oil stains

* Roads and signaling in disrepair

* Lifting Equipment in disrepair

* Unprotected conveyor belt

* Moving gears or pulleys unprotected

As substandard actions were personal factors that made them appear in substandard conditions exist that make them appear origins. A factor that explains the substandard conditions we call labor factor.

Causes origins of substandard conditions or factors work can be divided into:

1. – Normal or abnormal wear

2. – Abuse by users

3. – Inadequate design

4. – Inadequate Maintenance

Normal or abnormal wear

Normal wear and tear is a natural process to any equipment or material, the use and time produced. There comes a time when the wear becomes a substandard condition. Before that moment occurs should be exercised to avoid risk. It is essential to keep a log of equipment, materials or parts to be certain when replacing or repairing.

Abnormal wear is caused by abuse of equipment or tool, which should be corrected with training and inspections.

Abuse by users

We often find that good tools and equipment used for other purposes. This damages the tool, causing substandard conditions. For example, using a screwdriver as a lever, to hit pliers, etc..

Inadequate design

Moreover, we find that the facilities have not always considered the safety of its operation. This is the origin of substandard conditions. Within the design must include sufficient space, proper lighting, ventilation, transit areas, etc.

Inadequate maintenance

Inadequate maintenance is also the source of substandard conditions. The failure to replace old equipment, lack of spare parts, cause conditions to cause accidents.

In both definitions, were said to be made that … “Cause an accident”. This means that they can exist without accidents. Actions and conditions may occur without being absolutely necessary accident occurs. This will depend on the degree of risk of the actions and conditions existing at the time. There will be some increased risk, and the possibility of accidents will increase. There will be other less risky, in which the potential will be lower.

+ The important thing is substandard conditions and actions to detect and control time. The greatest potential risk of loss is one that is not known.

+ The accident can occur when working with unknown or uncontrolled risk.

When many actions and substandard conditions are not controlled, worker morale deteriorates, and eventually more accidents. It is therefore important to be aware of the need to strive for the elimination of all actions and substandard conditions.



According to the diagram, what to avoid “is the origin of”, because when it occurs, can cause serious consequences for the integrity of people, equipment and facilities and the environment. Then these elements form a chain that requires us to act definitively in origin, that is, avoid the causes if we really succeed in the ultimate goal of prevention.

11. Factors accidents

We have seen the causes of accidents, because they are the main focus of attention, if we prevent them. However, there are other factors accidents are also important to prevent them.

Source of accident

The source of the accident is the work that the person executed at the time of occurrence of the event.

Accident Agent

The agent is the physical element of the environment that has direct involvement in the generation of the accident. Normally we can classify, for example: materials, production methods, buildings, emery, etc..

Type of Accident

The type of accident is the way in which contact occurs between the person and the ambient object.

12. Classification of the types of accidents

1. – Accidents in which the material is to man.

* Beaten by

* Carlito

* Contact

2. – Accidents in which the man goes to the material.

* Paste against

* Contact

* Imprisoned by

* Fall at

* Fall underpass

3. – Accident in which the relative motion is indeterminate

a. Above effort

* For exposure

Each of the types of accidents are specific preventive measures, so that the more we know about them, the easier it will prevent accidents.

13. Domino sequence

One way that is often used to explain the sequence of events that trigger an incident or accident, through a domino pieces, figuring that the first domino to fall, bounce the following.

The sequence of events that trigger in an accident will be explained with the analysis of the result, last domino, which is the loss.

1. – Losses / costs



Slightly lower


MAYOR disabling



Once the complete sequence has taken place, there is a loss of workers and / or property.

The results of accidents can be evaluated according to worker injury and property damage, as well as human and economic effects. This situation is best plotted in tab 5 of the domino sequence.

2. – Accident / contact

When contact occurs with the power source, the capacity limit of the structure body or the accident occurs that generates loss.

Accidents, usually classified according to their class listed above.

3. – Immediate causes / symptoms

Accidents have causes and the causes can be known, identify, eliminate or control.

The acts of individuals and environmental conditions can be dangerous, unsafe or substandard.

4. – Basic Causes / real problems

When the emphasis is on correct substandard acts and conditions that cause accidents, we are correcting the “symptoms” and not the real problems that have led to these acts and conditions.

Underlying causes designated as personal factors explain why workers do not act as they should act.

Underlying causes of work designated as factors, explain why there are created or substandard conditions.

5. – Lack of control / management

The last tab, or the first that triggers the fall of the following represents the “lack of control” of the administration. The word “control” is used herein to refer to one of the five functions of any professional manager, plan, organize, lead, control, coordinate.

This tab relates to organizational and administrative deficiency overall business, there are programs inadequate, inadequate standards, breach of standards or lack of programs and / or standards.

If not set a training program, workers will not know to do assigned work or not have optimal productivity, if not defined the program selection and placement of personnel, in terms of knowledge, skills, physical and mental, is send jobs to workers who can not perform adequately.

The simple fact that many supervisors are not aware of the participation is expected of them in a security program, preventing them from doing the job properly and this can only cause the fall of the first domino, starting the sequence of events that lead to loss .

This domino represents the degree of involvement and commitment of senior management to workers andthe company, represented in the standards and safety plans.

Current Method

Currently using a fuller domino sequence is clearer where preventive action and costs. This sequence is shown in the figure below.

This updated domino sequence, makes it clearer where the control system acts operational risk is the “before” to generate the movement that dominated the other tabs bouncing going up to the accident.

14. Conclusions

No risk management plan is effective if it is accompanied by the support of senior management of the company, which should have a clear presence, permanent and visible to the lower levels of the organization.

From top management control depends accidents, losses, costs reduction, etc.

Top management shall prepare security plans to meet standards, should take permanent audits to assess the security system in the company, becoming expert advice for risk prevention or Industrial Safety Advisor.