 The failure of people, equipment,

materials and the environment to behave

and react as expected causes most of the
accidents.
 Accident investigations determine how
and why these failures occur.
 By using the information gained through
an investigation, a similar or perhaps
more disastrous accident may be
prevented.
 Conduct accident investigations with
accident prevention on mind.
 Investigations are not to place blame.
The Purpose:
 The purpose of accident investigation is to determine
cause or “why” an incident occurred.
 An accident may have a primary cause and several
contributing causes.
 “Carelessness” is not an acceptable cause due to the
fact that there is no reasonable way to correct or
prevent such behavior.
 More time may be needed to determine the underlying
or contributing causes.
 If the employee is disabled and off work, an interview
may have to wait until such time as he or she returns to
work.
• An undesired event that results in
harm to people, damage to
property, or loss to process.

• In general, an unplanned, unexpected,

and undesigned (not purposefully
caused) event which occurs suddenly
and causes (1) injury or loss, (2) a
decrease in value of the resources, or
(3) an increase in liabilities
 When the
personal If results in a
injury fatality or in a
requires permanent total,
little or no permanent partial
treatment , or temporary total
it is minor (lost-time)
disability, it is
serious
Similarly,
Investigate all
property accident
damage regardless of
may be the extent of
minor or injury or
serious damage
 All too often lives
are shattered
unnecessary
because of poor
working conditions
and inadequate
safety systems.

Kofi Annan
Secretary General, United Nations
 Throughout the world, there is
growing acceptance that accidents
and ill-health at work impact not
only on the lives of individual
workers, their families and their
potential for future work

Jukka Takal
SafeWork ILO
Do you know that due to work
connected ailments or injuries
there is an average of
6,000 people die everyday
equivalent to one every 15
seconds.

Source: ILO Data

 2.2 million deaths
per year including
438,000 deaths from more
Hazardous substances deadly
and 160 million work- than
connected diseases wars.
each year.

Source: ILO Data

 In the Philippines

 The incidence of work-connected

sickness, injury or death has
remained high through the years,
however, compliance with
reporting of work connected
accidents is very low.
 Accident are part of a broad
group of events that adversely
affect the completion of a task.
These events are incidents
 INCIDENT
 An undesired event which, under
slightly different circumstances,
could have resulted in harm to
people, damage to property, or
loss to process
 Detailed analysis of an accident
will normally reveal three level of
causes:

1. Immediate Cause

2. Basic Cause

3. Lack of Control
At the lowest level, an accident results only
when a person or object receives an amount of
energy or hazardous material that cannot be
absorbed safely.

 The Immediate Causes are the substandard

act and conditions or both.

 In turn, personal factors such as inadequate

knowledge/skills, stress and improper
motivation; and job factors such as
inadequate equipment, work standards,
maintenance, purchasing, and supervision
are the Basic Causes.
Immediate and Basic Causes

ACCIDENT / ILLNESS

HAZARDOUS HAZARDOUS
ACTS CONDITIONS

UNAWARE UNNOTICED
UNABLE UNCORRECTED
UNMOTIVATED
 Look beyond the direct causes of the
accident …

 Find out what can be done to

eliminate the underlying reason for
the hazardous behaviors and
conditions that led to the mishap
 Direct
Causes

Basic
(root)
Causes
Direct Causes

• caught in, between, or under

• struck against or struck by
• fall from or fall on
• overexertion or stress
Basic (Root) Causes

• inadequate maintenance of equipment

• inadequate codes and standards
• insufficient employee safety training
• safe work practices inadequately followed
• faulty design of work area
• supervisors not performing duties
 Bird’s Loss Causation Model
T
H
IMME- R
LACK OF BASIC
DIATE INCIDENT E LOSS
CONTROL CAUSE
CAUSE S
H
O
Inadequate Personal Standard Event L Harm
System Factors D
Acts/
Standard L Or
Job/ Practices
I
System Contact M Damage
Compliance Factors Conditions I
to Stds T
 Getting Medical Help
 When someone gets hurts in the
workplace, the most immediate need
will be to ensure that medical help is
quickly summoned.

 Most organizations have basic policies

and procedures on how to accomplish
this. Simple rules are the nearest to
remember and generally the most
effective.
 Famous line
“Pilitin mo man na
alisin ako sa buhay
mi, babalik at
babalik ako!
LIBAG
 Control the Situation
 If there is an immediate
continuing hazard, actions may
need to be taken to secure
unsafe situations prevent
to
injury to the investigators or
stability an unsafe situation for
co-workers.
 When to Start the Investigation
 Once the injured person has been provided
with the immediate medical assistance or
the incident situation has been stabilized,
the investigation should begin as possible.

Important Note:

Delays can easily result in a change in the physical

situation and surrounding circumstances.

Lighting levels change, noise levels change,

temperatures change, liquids evaporate and in
general, the situation changes.
 Cont. When to Start the Investigation
Important Note:

Additionally, the recall ability of witness to the event

will change. Even under ideal circumstances, memory
quickly fades with time.

 For accidents resulting in serious injuries it

may not be possible to interview the injured
person for several days or longer.

For this and other reasons, it is essential that the

scene of the accident be preserved until the essential
facts around the situation are determined.
 Cont. When to Start the Investigation
Important Note:

Immediate steps should be taken to secure the area:

- videotape the scene;

- take photographs;

- sketch the situations;

- take statements from co-workers and witnesses; and

- otherwise document the evidence at the site.

Actions not taken will result in difficulties in

accurately recreating the situation days and
weeks later.
 INTERVIEW
 In general, experienced personnel should
conduct interviews.

 All interviews should be conducted in a quite

and private location

 It is essential to get preliminary statements

as soon as possible from all witnesses.

 Investigators should not provide any facts to

the witness – only ask non-leading questions.
 INTERVIEW
1. Explain the purpose of the investigation
(accident prevention) and put each witness
at ease.

2. Listen, let each witness speak freely, and be

professional courteous and considerate.

3. Take notes without distracting the witness.

Use a tape recorder only with consent of the
witness.

4. Use sketches and diagram to help the

witness
 INTERVIEW
5. Emphasize areas of direct
observation. Label hearsay
accordingly.

6. Do not argue with the witness.

7. Record the exact words used by the

witness to describe each observation.

8. Identify each witness (name, address,

occupation, years of experience, etc.)
 PROBLEM SOLVING TECHNIQUES
Accidents represent problems that must
be solved through investigation.
Several formal procedures solve
problems of any degree of complexity.

The two most common procedures are:

1. Change Analysis; and

2. Job Safety Analysis

 Cont. PROBLEM SOLVING TECHNIQUES
The two most common procedures are:

1. Change Analysis

As its name implies, this technique

emphasizes change.

To solve a problem, an investigator must

look for deviations from the norms.

Consider all problems to result from

some unanticipated change.

Make an analysis of the change to

determine its causes.
Change Analysis
Compares how a job was
actually performed with the
way it should have been
performed
Change Analysis
ACTUAL
BEHAVIORS or
STANDARD
BEHAVIORS or
SAFE
BEHAVIORS or
CONDITIONS CONDITIONS
CONDITIONS

ACTUAL
BEHAVIORS or
STANDARD
BEHAVIORS or
UNSAFE
BEHAVIORS or
CONDITIONS CONDITIONS
CONDITIONS
Recommending Corrective
Actions

 Specific
 Measurable
 Attainable
 Realistic
 Time-bound
 Cont. PROBLEM SOLVING TECHNIQUES
The two most common procedures are:

1. Change Analysis

Use the following steps in this method:

a. Define the problem (What happened?)

b. Establish the norm (What should have

happened?)

c. Identify, locate and describe the change

(What, Where, When, to what extent.)

d. Specify what was and what was not affected.

 Cont. PROBLEM SOLVING TECHNIQUES
The two most common procedures are:

1. Change Analysis

Use the following steps in this method:

e. Identify the distinctive features of the

change.

f. List the possible causes.

g. Select the most likely causes.

 Cont. PROBLEM SOLVING TECHNIQUES
The two most common procedures are:

2. Job safety Analysis

Job Safety Analysis (JSA) is part of

many existing accident prevention
programs.

In general, JSA breaks a job into basic

steps, and identifies the hazards
associated with each step.

The JSA also prescribes controls for

each hazard.
 Cont. PROBLEM SOLVING TECHNIQUES
The two most common procedures are:

2. Job safety Analysis

JSA is a chart listing these steps, hazards and
controls.

Review the JSA during the investigation, if a

JSA has been conducted for the job involved
in an accident.

Perform a JSA if one is not available.

Perform a JSA as part of the investigation to

determine the events and conditions that led
to the accident.
 Famous line
“Anung kasalanan
ko sayo, iniwan mo
nalang akong
duguan
NAPKIN
 REPORT OF INVESTIGATION
 An accident investigation is not complete
until a report is prepare and submitted to
proper authorities.

 Special report forms are available in many

cases.

 Such reports are often very elaborate and

may include a cover page, a title page, an
abstract, a table of contents, a commentary
or narrative portion, s discussion of probable
causes and a section on conclusion and
recommendations.
 Cont…REPORT OF INVESTIGATION
The following outline has been found especially
useful in developing the information to be
included in the formal report:

1. Background Information

a. Where and When the accident occurred

b. Who and what were involved

c. Operating personnel and other witnesses

 Cont…REPORT OF INVESTIGATION
The following outline has been found especially
useful in developing the information to be
included in the formal report:

2. Account of the Accident (What happened)

a. Sequence of events

b. Extent of damage

c. Accident Type

d. Agency or source (of energy or hazardous

material)
 Cont…REPORT OF INVESTIGATION
The following outline has been found especially
useful in developing the information to be
included in the formal report:

3. Discussion (Analysis of the Accident – How,

Why)

a. Immediate Causes (Substandard Acts;

Substandard Conditions)

b. Basic Causes (personal and Job Factors)

 Cont…REPORT OF INVESTIGATION
The following outline has been found especially
useful in developing the information to be
included in the formal report:

4. Recommendations (to prevent a recurrence)

for immediate and long-range action to
remedy)

a. Immediate Causes

b. Basic Causes
 Workshop – Gathering of Facts
I. Actual Accident or Simulated Accident

- Nature of accident

- Parties Involved/ responsible person(s)

- Place of Accident

- Time and date of Accident

II. Interview witnesses/victims

- 5 W’s and 1H develop at least 20 question

III. Collected evidence, photographs, records review

IV. Presentation:
This is to inform you regarding the accident that happen
at the site of our project, project: project site
Columbos Seafood Corporation, Talisayan Zamboanga
city where in Mr. XXX fall from the roofing at around
11:00PM of December 20,2007, which causes his
bruises on his left foot and right hand. Said Accident
happen because he saw that there was a big flame
that cause out of the acetylene oxygen tank that
make him nervous and decide to jump from the said
roof.

The victim was immediately brought to the Company

Clinic for treatment.

For your information and guidance.

Engr. Ramos
On March 22, 2010 at around 5:00PM an accident happen
in the project site, when laborer A was about to go
down the stair was accidentally slip on the newly
installed tiles and hit his head on the floor causing A
swelling in his forehead and immediately we rush him
to the nearest hospital for medical check-up and
treatment.

Upon investigation of the cause of accident, the victim

slip on the newly installed tiles, bec he step on the
uninstalled tiles that was left on top of the installed
tiles, causing it to slip. He accidentally step on it.

So therefore the cause of accident is due to lack of

housekeeping after working hours.

Safety Officer Edmond Salvador.

At 11:30AM of 28th of March 2010 Max Bernardo
a carpenter at the two store residential
building construction accidentally fell down
appx. 6 meters from the ground due to the
breakge of
 WHO
… was injured?

… saw the accident?

… was working with the injured?

… had instructed/assigned the job to the

injured?

… else was involved?

… has the information of events prior to the

accidents?
 WHAT
… is the injury?
… is the damage or loss?
… was the injured doing?
… had the injured been instructed to do?
… did the injured & any witnesses saw?
… training had been given?
… were the contributory causes of the accident?
… communication system is used?
… safety rules were violated?
… safety system and procedures were there?
 WHEN
… did the accident occur?
… did the damage become evident?
… did the injured start the job?
… was the explanation of hazard given?
… did the supervisor last see the injured?
… did the persons involved last have food and
rest
 WHY
… did the injury occur?
… did the communication fail?
… was the training not given?
… were the unsafe condition permitted?
…was the hazard not spotted at previous inspection?
… was PPE not provided?
… was PPE not used?
… was there no safety instruction given?
… was the supervisor not consulted when things started go
wrong?
… was the supervisor not there at the time?
 WHERE
… did the accident occur?
… did the damage occur?
… was the supervisor at that time?
… was the witness at that time
 HOW
… did the injury occur?
… could the accident have been avoided?
… could have been injury avoided?
… could the supervisor have prevented the
accident?
… could better design help?
 ACCIDENT INVESTIGATION
(General Process Flow)

Gather facts
Ensure about the
immediate Secure the accident:
medical area
treatment witnesses

Document
Identify the
the facts:
Follow- Corrective root cause
hard
up (causal
action evidence,
factors)
witness
 OSH STANDARDS
RULE 1050 - Notification & Keeping of
records of Accident and/or Occupational
Illnesses
Section 14 of D.O. 13 s. 1998 – Construction Safety and Health Reports
 1053.01: Notification - All work
accidents or occupational illnesses, resulting
in disabling conditions or dangerous
occurrences shall be reported by the
employer to the Regional Labor Office
 If Major work accidents results in death or
permanent total disability, employer shall
initially notify the Regional Labor Office
within 24 hours.
 OSH STANDARDS
RULE 1050 - Notification & Keeping of records of
Accident and/or Occupational Illnesses
 1054: Keeping of Records - The employer shall
maintain and keep an accident or illness record
which shall be open at all times for inspection to
authorized personnel containing minimum data:
a. Date of accident or illness
b. Name of injured or ill employer, sex and age
c. Occupation of injured or ill employee at the time
of accident or illness
d. Assigned causes of accident or illness
e. Extent and nature of disability
f. Period of disability (actual and/or charge)
g. Whether accident involved damaged to materials,
equipment or machinery, kind and extent of
damage, including estimated or actual cost
 OSH STANDARDS
RULE 1050 - Notification & Keeping of Accident and/or
Occupational Illnesses ,
Required Report
OSH RULE REPORT/FORM WHEN TO REPORT WHERE TO
REPORT

Rule 1050 Work Accident Illness -On or before the 2 copies, to

Notification and Report (WAIR) - 20th day of the be submitted
Keeping of DOLE/BWC/IP-6) month following the to concerned
Accidents WAIR date of occurrence of RO copy
and/or the accident furnished the
Occupational Bureau
Illnesses
Annual Exposure -On or before Jan. 20
Data Report (AEDR) - of the following year
(DOLE/BWC/IP-6b)

Fatal/major accident Shall initially notify

the DOLE ROs within
24 h ours
 DOLE Forms
 1. DOLE/BWC/OHSD/IP-6
Employer’s Work Accident/Illness Report
(This report shall be submitted by the employer for every accident or illness to
the Regional Office having jurisdiction on or before the 20th day of the month following
the date of occurrence)

2. DOLE/BWC/OHSD/IP-6a
Government Safety Engineer’s Accident
Investigation Report
(This report shall be submitted to the Bureau of Working Conditions not later
than the 30th day of the month following the date of occurrence)

3. DOLE/BWC/OHSD/IP-6b
Annual Work Accident/Illness Exposure Data Report