Accident investigation summary

By the late George Robotham

The term accident is an emotionally laden term that implies blame. I prefer to use the term personal damage occurrence.

Summary of the personal damage occurrence investigation process

1. Provide first-aid and medical care to injured persons and make the site safe
2. Ensure Emergency Response Plans are activated
3. Report the event as required by local regulations and site procedures.
4. Secure the site until the organisation’s and regulator’s investigation is complete.
5. Notify next of kin
6. Investigate and report essential factors.
7. Have relevant persons sign a written statement
8. Use open questions.
9. Take heaps of photos from many angles
10. It may be appropriate to develop a sketch or diagram
11. Take samples, tag & preserve them
12. Do not move evidence
13. Identify the people involved and isolate and separate them. Interviews at both the scene and a quiet place will probably be required. It is essential to put those being interviewed at ease
14. It may be necessary to recreate the incident with due regard to safety
15. Report the findings
16. Develop a plan for short- and long-term corrective action
17. Disseminate key learnings to stakeholders
18. Implement the corrective action plan
19. Obtain sign-off by management
20. Evaluate the effectiveness of the corrective action
21. Make changes for continuous improvement
22. Notify other sections of the organisation and your industry about the circumstances of the incident.

Personal Damage Occurrence Investigation Models

The author has been exposed to a number of investigation models-Root cause analysis, Tripod, I.C.A.M., Tap Root and A.R.T.T. Of the above the author has found A.R.T.T. (Analysis Reference Tree Trunk) the most useful. This method was developed by Brisbane OHS consultant, Geoff McDonald.

Essentially the personal damage occurrence is represented by a tree-trunk lying on the ground, at the end of the tree-trunk you have Person elements, Machine elements and Environment elements, along the length of the tree-trunk you have 6 time zones and the annular or growth rings of the tree represent a number of Ergonomic elements. Instead of looking for “causes” you look for “essential factors” ( An essential factor is one without which the final personal damage could not have occurred) There are good reasons why the term “cause” is not used. The idea is to look for essential factors where the various categories of the model above intersect.

The model is very easy to use and usually at least 30 essential factors will be found in each personal damage occurrence. The author hears good reports on training in this technique conducted by Intersafe.

American author Ted Ferry has written publications that provide practical, how to advice on this topic.