Dr.S.P.

SIVAPIRAKASAM

REASONS FOR ACCIDENT

INVESTIGATION
1. To identify System Deficiencies aiding in
process improvement
2. To identify hazards and hazard mechanisms
thereby improving the hazard control process
3. To aid in the financial resolution to
compensate injured parties for the effects

REASONS FOR ACCIDENT

INVESTIGATION
4. To resolve regulatory issues
5. To reconcile labor relations issues
6. Others ??????

Principles Which Underlie

Accident Investigations
Every accident is a symptom of a system
failure
Accident prevention requires a team effort
Accident investigations should follow formal
logical methodologies
Communication of lessons learned from the
investigation is essential

Types of Accident Investigations

Type I Traditional informal
investigation conducted by immediate
supervisor
Type II Committee based
investigation using expert knowledge
of individuals
Type III Multiple cause, systemfocused investigation

Accident

Mitigation of Effects
Spill Clean Up
Fire Suppression
Medical Treatment
Personnel Rescue

Return to Normal Operations

Remove Debris
Cleanup
Replace/Repair
Restore Utilities

Reporting
Notification
Company Officials
Government Agencies
Media
Insurers

Fact
Finding
Collect & Save Evidence
Interview Witnesses
Make Photographs &
Videotapes
Create Diagrams

Class Exercise

Response to Incidents
A research laboratory of three (3) stories and a total
floor space of 10,000 square meters houses
activities requiring the use of flammable and
unstable chemicals with supporting storage space.
You are the ESH Manager on site. Early one
afternoon you hear a loud explosion coming from a
ground floor laboratory where two (2) chemists
apparently had been working. A fire was underway
and was about to escape from the room where the
explosion had occurred.
Make all necessary assumptions and list in order the
steps that would be best taken in a complete
response to this incident.

Accident Investigation in India

Factories Act ( 1948 Amended in 1987) SECTION 90
State Government may initiate an accident
investigation for any accident occurring in a
factory
State Government may also investigate illnesses
that might have been contracted in a factory
State Government may also appoint a competent
person to investigate the incident or illness
> Has powers to interview witnesses
> Has powers to enquire documents and
material objects

Accident Investigation in India

Factories Act (1948 Amended in 1987) SECTION
88 and 88A

Manager of Factory must report deaths and

serious injuries likely to cause death and also
dangerous occurrences (of events below).

> Pressure vessel, pressurized line or

equipment failure
> Collapse of crane, derrick or hoist

Accident Investigation in India

(Continued)

> Overturning of Crane

> Molten metal explosion where persons are
employed
> Gas or liquid leakage or explosion where
persons are employed
> Fire where cotton opener is in use
> Collapse or subsidence of any structure,
bridge or tunnel

India Reporting Requirements

Factories Act (1948 Amended in 1987) Section 89
Factory Manager must report poisoning from:
> Carbon Bisulfide
> Lead
> Benzene
> Phosphorus
> Nitrous Fumes
> Mercury
> Anthrax
> Manganese
> Silicosis
> Arsenic
> Signs of skin cancer
> Toxic Anemia
due to radioactive
> Halogens or their
substances
aliphatic derivatives
exposure

India Reporting Requirements

Factories Act (1948 Amended in 1987) section 88 and 88A

To whom should reports be made?

Deaths and serious injuries likely to cause
death or dangerous occurrences must be
reported to the following:
District Magistrate or Subdivisional Office
Officer in charge or nearest police station
Relatives of injured or deceased persons

Written report to the above authorities within

12 hours

India Reporting Requirements

Factories Act (1948 Amended in 1987) section 88, 88A &89

Other Reports
When injured or ill persons from incidents, or
from dangerous occurrences in the factory,
can not work after 48 hours following the
event, the Factory Manager must report to the
Inspector within 24 hours following the 48
hour period.

India Reporting Requirements

Factories Act (1948 Amended in 1987) section 88, 88A &89

Other Reports
After initial reports have been submitted, if
the injured or ill person should die, the
Factory Manager must notify the authorities
mentioned earlier by telephone, telegraph or
messenger and confirm the event within 12
hours of the death

India Reporting Requirements

Factories Act (1948 Amended in 1987) section 88, 88A & 89

Other Reports
If cases of chemical poisoning or
radiation damage occur involving
agents mentioned earlier, the Factory
Manager must notify the Chief
Inspector and the Certifying Surgeon

India Reporting Requirements

Factories Act (1948 Amended in 1987) 89

The Manager of every factory

must maintain a register of all
accidents and dangerous
occurrences which occur in the
factory

Class Exercise

Response to Incidents
In the case considered earlier, involving
explosion and fire, discuss the case further
and list the reports that would be required in
this situation. Assume that the final effects
from this incident were as follows:
1. One Chemist killed
2. One Chemist burned and not expected to live
3. One facility Fire Brigade member burned and
recovering. Returned to work after 5 days.
4. Spill of Sulfuric Acid amounting to 1000 Liters
or more. Fire Brigade members exposed.

Class Exercise
Sit with your team and watch Part 1
of the Videotape
Answer the questions below, make a list
and be prepared to discuss this with
other groups
1. What are some of the things that were
done wrong by the Warehouse
Supervisor in responding to this
accident?
2. What should have been done instead?

Accident Investigation Planning

Documents
1. Accident reporting policy
2. Accident investigator/analyst team
organization
3. Accident investigator/analyst
training requirements
4. Inventory listing of
tools/equipment needed for
accident investigation

Accident Investigation Planning

Documents
5.
6.
7.
8.

Accident reporting forms

Distribution lists for accident reports
Procedures for report
Procedures for recommendation
review, implementation and follow-up

Planning Matrix
Super-big Warehouse Store - Customer Injury Accident
Activity

Store
Mgr.

Store Mgr.
& Dept.
Heads

Assistant
Store
Manager

Respectiv
e Dept.
Head

Store
Security
Chief

1.

Take injured to hospital

2.

Secure area

3.

Do preliminary survey

4.

Identify witnesses

5.

Identify items for photography

6.

Interview witnesses

7.

Tag items for photography

8.

Photograph scene

9.

Interview medical personnel

10.

Collect pertinent records

11.

Review evidence

12.

Determine if special
investigators are needed

13.

Complete accident report

14.

Review report

X
X
X
X

Investigators Kit
TOOLS

Flashlight, 3 cell explosion

proof, or lantern
Spare batteries and bulbs
for flashlight
Steel tape measure100 ft.
Scale12 inch ruler or NU
Traffic Template
Protractor
Pliers
Wrenches, small adjustable
or box end
Wire cutting pliers
Screwdriverslarge,
medium Philips

Knifesmall sheath or 3
inch blade pocket
Sawwood and metal
cutting blades
Compass
Magnifying glass
Inspection mirrorslarge
and small dental
Toothbrushnatural bristle
Nails12d common
Ropenylon 50 ft.
Twine string300 ft package
wrapping

Investigators Kit (Continued)

SPECIAL EQUIPMENT

Camera with flashgun

Flashbulbs and film
Cassette tape recorder and cassettes
Sound level meter
Gas vapor analyzer
Electrical receptacle tension tester
Calipers, inside and outside diameter

Investigators Kit (Continued)

MEDICAL EQUIPMENT

Water
Triangular bandages
Adhesive tape1 inch
Peroxide
Hand cleaner, waterless
Eye drops and ointment

Investigators Kit (Continued)

ADMINISTRATIVE SUPPLIES

Investigators field work

book
Clipboard
Note pads, lined, 8 x 11
Plastic bag to cover
clipboard
Graph paper inch
squares
Accident report form
Witness interview statement
Pocket portfolio
Envelopes, manila 9 x 12
Aluminum foil roll

Paper towel roll

Adhesive labels 2 x 3 inch
Felt tip markers
Ballpoint pens
Soft, Nr 3 pencils
Yellow lumber crayon
Black grease pencils
Orange spray paint--small
Eraserart gum
Scotch tape
Masking tape2 inch
Cardboard tags, string

Investigators Kit (Continued)

SPECIAL DEVICES

Engineers scale
Metric conversions
Wire rope/hemp rope size calculators
Fluid sample containers
Pin marking flags, 18 inch

Investigators Kit (Continued)

PERSONAL PROTECTION

Hard hat
Glasses, protective
Gloves, leather or canvas
Gloves, linemans
Ear plus
Vest, orange flagmans

Overall Accident Investigation

Process
Evidence collection
Analysis and reconstruction
Develop findings and
recommendations
Write accident investigation report
Follow up

Functions of Investigator
To locate and identify evidence which
may relate to a loss incident
To examine the evidence
To ascertain its relationship to the loss
incident
To reconstruct the events leading up
to the loss incident
To develop conclusions about
measures needed to prevent a
reoccurrence

Four Types of Evidence

People
Position
Parts
Paper

INCREASING
FRAGILITY

People Evidence Exercise

Sit with your class group once again and

review the videotape about the
Warehouse Accident. Develop answers
to the following questions:
1. What aspects of the interview shown in the
videotape were conducted in an improper
way? Make a list.
2. For each item on your list, describe how the
interview should have been conducted.

Accident Site Map

MR

POSITION

A
B

AA
C

BB
FF

CC

EE

DD

Date 5-16-69
Identification

Position Data
Key

Item

Mr. A Injury

Reference Point

Distance

Direction

AA

Grinder
Tool Shop Doorway

Wheel on Rt. end

13 ft.

110

11 oz piece grinder
wheel

AA, Rt. end

BB
B

13 ft.
8 ft.
3 ft.

70

AA, Rt. end

BB

16 ft.
6 ft.

Scar on Wall

340
316
86
360

Chisel

AA, Rt. end

4 ft.

130

Protective Goggles

AA, Rt. end

7 ft.

340

CC
DD

Sand blast machine

Shop Supervisor
Desk

AA, Left end

6 ft.

180

EE
FF

Shop Supervisor
Witness_______________

AA, Left end

AA, Left end

14 ft.
12 ft.

140
120

Uses of Photography

General orientation to the scene

Detailed record of injury and damage
Relative positions of people and parts
Witness view of the scene
Details of marks, spills, signs,
instructional aids, etc.
Disassembly of parts detail for analysis

Taking Photographs
Photograph important evidence twice
Take medium distance photographs
(midrange) that show the evidence and its
position relative to other evidence
Take close-up photographs that include a
scale and fill the frame.
Prior to entering the scene, acquire prior
photographs, blueprints or maps to the
scene.
Adapted from FBI Handbook, 2003

Photo Log

Position Evidence Exercise

Please sit with your class group and
review the videotape on the Warehouse
Accident. Then answer the following
questions:
1.What mistakes were made when obtaining
position evidence in this investigation.
Please make a list.
2.What steps should have been taken instead.

Please make a list and be prepared

to discuss it with the class.

Parts Evidence
Parts can be solid, liquids or gases
Parts that should be considered for
further examination:
Any components which are fractured,
distorted, scarred, chafed or ruptured
Parts requiring lubrication
Controls and displays
Substituted or modified parts
Parts showing signs of leak or age along
with stains or spills

Parts Evidence (Continued)

Foreign objects that seem different in size,
shape, color, smell, or location
Parts suspected of internal failure, or
abnormal stress
Parts suspected of improper assembly or
mating
Parts improperly mounted or supported
Power sources and vital electrical
components

Tags for Identification of Parts Removed

from an Accident Site for Analysis

Testing of Parts

1. Visual Examination
2. Dimensional Measurements
3. Nondestructive Evaluation
4. Chemical Analysis
5. Mechanical Testing

Non-destructive Evaluation
1. Visual Examination
2. Leak Testing
3. Liquid Penetrant Inspection
4. Magnetic Particle Inspection
5. Eddy Current Inspection
6. Ultrasonic Inspection
7. Radiography
8. Acoustic Emission Inspection
9. Thermal Testing
10. Microwave Inspection
11. Magnetic Field Testing
12. Halography

Types of Paper Evidence

A. Facility Records
1.
2.
3.
4.
5.
6.
7.
8.
9.

Construction (blueprints, design specs)

Equipment installation records
Preventive maintenance records
Facility/equipment inspection records
Damage reports or maintenance requests
Construction progress photos
Building acceptance records
Roadway or topographic maps
Equipment breakdown/failure records

Types of Paper Evidence

B. Personnel Records
1. Skill Level Verification
a. Certification/licenses
b. Trade union records
c. Employee training
d. Skill certification test records
e. Operating manuals
f. SOPs
g. Training course manuals
h. Employee appraisal and counseling

Types of Paper Evidence

B. Personnel Records (continued)
2. Other Personnel Records
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Supervisor training records

Supervisor selection/hiring
Safety training of supervisor
Supervisor appraisals
Employment applications
Employee physical exams
Employee safety training
Employment history
Company job orientation records
Other

Types of Paper Evidence

C. Purchasing Records
1. Standards/specifications
2. Safety reviewsafety buy-in
inspection
3. Receiving records

Types of Paper Evidence

D. Safety Records
1. Hazard analysis results
a. PHA
b. JSA
c. HAZOP or other

2. Accident reports
3. Hazard reports

Paper Evidence Exercise

Sit again with your class group and watch the
videotape on the Warehouse Accident. Then
answer the following questions:
1. What paper evidence did the company have that
they could use in investigating this accident.
Make a list.
2. What other records should they have had to
assist them. Make a list.

Unique Features of Chemical

Process Incident
Investigated in a similar approach to a fire
investigation because these are often accompanied by
fire.
Follow the 4Ps to collect evidence
During the incident reconstruction, the first initiative is
to locate the source of the explosion.This will be the
spot where the greatest temperature was located and
where the most damage occurred.
A scatter pattern of exploded parts can also help
identify the source of the explosion.
Once the source is located, a Fault Tree Diagram can
be used to find the requisite states and events that led
to the explosion.

Finding the Source of Explosion

Finding the Source of Explosion

Dust Collection
Drum

Dust Collection
Drum

Aluminum Atomizing unit

Cyclone Separator

Fine Dust Collector

Explosion Vent

Rotary
Valve

Non-Return
Valve
Explosion Vent

Fine Dust Collector

Blowing
Chamber

Rotary
Valve

Non-Return
Valve

Explosion Vent
Air Receiver

Cyclone Separator

Nozzle
Outlet for Jet

Explosion Vent

Compressor

Valve
Handle

Blower

Dust Collection
Drum

Dust Collection
Drum

Furnace
Control
Room

Charging Door

Explosion at
furnace area and lead to
Two fatality

Preheater

Pump
Ingot Storage

Underground
Storage

Electrical Panel

Fault Tree Analysis

Fire & Explosion at
furnace room

Furnace
fire

Burner
Maintenance

Dust Collection at
Collector

Dust concentration
within explosive
range

High
Temperature

No Suction

No Suction

Source of
Ignition

Dust
ventilator
off due to
Mechanical

Dust
ventilator
off due to
Electrical

Dust
ventilator
off due to
Mechanical
2

Dust
ventilator
off due to
Electrical

Mechanical/
Electrical
Spark

High Earth
Resistance
5

Static
Electricity

Minimal cut sets

1, 2-3-4, 2-3-5, 2-3-6, 23-4, 2-4, 2-5, 2-6, 3-4, 3-5, 3-6.
Risk probabilities
Burner problem may cause fire &
explosion at collecting chamber
entrance
No suction combined with any one
of the source of ignition may
cause fire & explosion at collecting
chamber entrance

Insufficient
earth
conductive
rod
6

Types of Incident Causes

Primary
Immediate
Appearance

Fundamental
Root
Basic
Underlying

PROXIMAL

DISTAL

IDENTIFY A
POTENTIAL
CAUSAL
FACTOR

ANALYZE
EVIDENCE

YES

HYPOTHESIS
PASSES
TEST

DEVELOP A
HYPOTHESIS
ABOUT A
RELATIONSHIP
BETWEEN
CAUSAL
FACTORS
TEST HYPOTHESIS
AGAINST LOGIC
AND EXPERIENCE
DATA

NO

NO

IS MORE
EVIDENC
E
NEEDED?

COLLECT
MORE
EVIDENCE

Pareto Analysis and the 5 Whys

1. For the causal factors listed as
important by the accident investigation
team.
2. Causal factor #1
Why?
Why?
Why?
Why?
Why?

3. Preventive Measures:

Accident Reconstruction
Place items on a fishbone under category:
METHODS, MATERIALS, MANPOWER, MACHINERY of
ENVIRONMENT
MACHINERY

METHODS

MANPOWER

MATERIALS

ENVIRONMENT

Guidelines on the Contents of the

Investigation Report

Location and identity of the reporting organization

Identity of the Investigation Team
Type of incident
Description of loss
Description of the incident
Activities of the Investigation Team
Sources of evidence to be presented
Presentation of the evidence found
Listing / discussion of the various causation factors
Recommendation and justification of necessary corrective
actions

Incident Causation Models

1.
2.
3.
4.
5.
6.
7.
8.
9.

Domino Theory
Revised Domino Theory
Energy Release Model
Accident Proneness
Epidemiological Model
Multilinear Sequencing
Ergonomic Models
Swiss Cheese Model
Universal Model

Domino Theory

Revised Domino
Theory

Energy Release Model

1. Informally devised and used by the
Engineering Profession
2. Identified the Loss Incident as the
point where energy was released or
transformed.
3. Failed to address health hazard
exposures
4. Valid but incomplete
5. Limited applicability
for management

Accident Proneness Model

1.Devised and kept alive by Psychologists
2. Guiding principal held that because of
individual limitations, certain people are
most likely to have accidents
3. Managers used this theory to justify the
firing of accident repeaters
4.Does not address the occurrence of
occupational disease
5. Statistically invalid and not useful

Epidemiological Model
Used by the Medical Profession
Consists of three elements (Agent, Host
and Environment)
Utilizes the sophisticated collection of
statistics to show who and where people are
experiencing adverse final effects.
Usually does not reveal how Loss Incidents
are occurring and this limits its usefulness.

Multilinear Sequencing Model

* Devised by Ludwig Benner in the US DOT.
* Up to this time theorists had portrayed
incident causation as a unilinear process like
the Domino process.
* Benner found that airline crashes were
caused by an independent parallel series of
causal factors
* Does not identify individual causal factors nor
does it address health hazards.

Ergonomic Models
Address human limitations as a causal
factor for certain types of workplace
injuries.
Tries to predict the limits of human
exertion that should be tolerated in
workplace tasks.
Only addresses a narrow spectrum of
loss incidents
Not applicable to fires, explosions, car
crashes, etc.
Lesson #6 Page #14 Slide #40

Universal Model
1. So named because it can be applied to
all types of Loss Incidents
2. Distinguishes between Proximal and
Distal causal factors
3. Uses a Point of Irreversibility to
separate causes and effects.
4. Considers Aggravating and Mitigating
Factors which affect the severity of
Final Effects.

Universal Model Definitions

Proximal Causal Factors those states and events
which are necessary for the occurrence of a Loss
Incident and which occur or exist at the time and
place of the Loss Incident. Three (3) types:
> Chemical, Physical or Biological Conditions
> Human Actions or Inactions
> Exceeded Functional Limitations

Distal Causal Factors those management

policies and practices that do not occur just at the
time and place of the Loss Incident but instead
allow the Proximal Causal Factors to occur or
exist.

Universal Model Definitions

Point of Irreversibility (POI) that state or event in the Loss
Incident sequence when it is reached, circumstances can no
longer be returned to their original condition. When this point
is reached, by definition, a Loss Incident will occur. Separates
causes from effects.
Aggravating Factor a state or event which occurs after the
POI and makes the Final Effects worse than they otherwise
would be.
Mitigating Factor a state or event which occurs after the POI
and keeps the Final Effects from being worse.

Lecture #8 Page #18 Slide #53

Steps to Constructing a Universal

Model Diagram
Find the Point of Irreversibility
.2. Find the first Loss Incident (without any subsequent events
or states can
produce effects or a near miss).
.3 .Connect these two points
.4. Add any Aggravating or Mitigating Factors
.5 Find the next Loss Incident (if any)
.6. Add Aggravating or Mitigating Factors between Loss
Incidents
.7 Find all remaining Loss Incidents (if any)
.8 Identify and list the Final Effects
.9 Identify Proximal Causal Factors i.e. hazards which
immediately
precede the Point of Irreversibility
10 .Identify the Proximal Causal Factors which precede these
hazards
11. Show only hazards that meet both of the following
requirements:
1.

Universal Model Symbols

 Exhibit 2. It can be shown that each of the

three (3) Proximal Factor types can cause
both of the other two (2)
#57

Some Examples of Loss

Incidents

Worker Falls
Sharp Edge Penetrates
Workers Skin
Tank Explodes
Insulation on
Conductor Melts
Worker Experiences
Heat Exhaustion
Driver Loses Control of
Vehicle
Methane Gas Ignites
Water Enters Cargo
Hold of Ship

Lecture # 8

Electrical Current
Passes Through the
Body
Intruder Fires Weapon
Worker is Struck by
Forklift
Tendons in Wrist are
Overstressed
Fire Spreads to Ceiling
Tile
Scaffold Fails
Sensitizer Contacts Skin

Page #20 Slide #59

Universal Model Example

In an accounting office, contractors were installing new cables for
an upgraded computing system. Accounting Department employees
continued to work at their desks in the same area where installation
work was being performed. One contractor employee was preparing
to install an outlet in a wall behind a desk, a task for which he was
using a portable electric cord connected drill. He attached an
extension cord to the drills power cord since there were no nearby
outlets. Then he laid the cord on the floor across the aisleway in
front of this desk. A few moments later, while the contractor
employee was operating the drill, the telephone rang on a nearby
desk No one was near the telephone but one employee about 40 feet
away hurried to answer it. In her haste, the employee did not notice
the cord stretched across the aisleway. She tripped over the cord and
fell hard onto the floor. She suffered a broken arm and missed four
(4) days work.

Universal Model Example

Universal Model Example

Universal Model Example