Accident Investigation and Reporting

Occupational Health & Safety
Practitioner
Reading
ACCIDENT INVESTIGATION AND

REPORTING
January 2009
®
Contents
OVERVIEW .....................................................................................................................1
SECTION 1: GETTING STARTED.................................................................................2
SECTION 2: THE INVESTIGATION ..............................................................................7
SECTION 3: RESEARCH ............................................................................................14
SECTION 4: ANALYSIS...............................................................................................16
SECTION 5: REPORTING ...........................................................................................20
SUMMARY ....................................................................................................................24
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The SafetyLine Institute material has been prepared

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SafetyLine Institute website.
READING – ACCIDENT INVESTIGATION AND REPORTING
OVERVIEW
"An investigation is a search for the truth, in the interests of justice

and within the constraints of the law."
P G Nendick - The Investigation Handbook
The objective of this reading is to provide learners with an

overview of what is involved in an accident or incident
investigation, what equipment is needed, where to start, what
evidence to look for, what research is required, how to analyse
your results, and what to do with the report when you have
completed it. This reading is designed to be a complete overview,
to enable the learner to understand the A to Z of investigation and
reporting, consequently each area will not be visited in great depth.
Objectives
After reading this information you should be able to:
 describe the purpose of an accident investigation;

 identify components of an investigation;
 describe methods of implementing investigation components;
and
 describe methods of reporting.
Author
Ron E Reid
JANUARY 2009 SAFETYLINE INSTITUTE PAGE 1

Section 1: GETTING STARTED
Introduction
An accident has happened at work. - Perhaps someone has been
injured. - What is the basic first step that needs to be taken?
Where do we start? The initial and fundamental step to
commence the process of accident investigation and reporting is
the notification to management that an accident or incident has
happened. The person best placed to initiate this action is the
person who was involved in the accident or incident and it should
be made to their immediate superior. The workplace should have a
system in place for notification and recording of all incidents and
injuries that have happened at the workplace.
After the accident or incident has been notified and recorded, there
should also be an automatic system in place to enable notification
to the appropriate personnel responsible for investigating these
occurrences including elected worker health and safety
representatives (if any).
What can we achieve from conducting an accident investigation?

We can't stop the person from being injured. We can't stop the
equipment involved in the accident from malfunctioning. We can't
stop the plant, building or equipment from being damaged or
rendered unserviceable.
We have already lost enough productivity as a result of the

accident, firstly from the equipment being out of service, then
waiting for the ambulance to arrive, and now trying to replace the
injured person, and the rest of the operators seem to be working
slower than usual. We have orders to fill and deadlines to meet. If
we conduct an investigation as well, we will have a huge loss of
productivity, people away from their usual job being interviewed,
consequently other employees relying on their work are at a
standstill. To investigate is reactive. We need to be pro-active.
Interesting and compelling reasons for not conducting an

investigation. Loss of productivity! Wow! - productivity - a buzz
word - let's face it, our pay and pay rises are based on productivity,
our employers very viability is productivity based.
PAGE 2 SAFETYLINE INSTITUTE JANUARY 2009

1.1 Why investigate?

Agreed, you cannot stop the person being injured, you cannot stop
the equipment or plant being damaged, you cannot stop the loss of
productivity that has occurred. You can, however, establish the
causal factors of the accident from which the hazard or hazards
can be identified. You can then identify the risks associated with
the hazards and develop preventative strategies to reduce the risk
of this or similar accidents happening, at this or similar workplaces,
again.
The reduction of lost time injuries in a workplace, industry, State or

Country has a major impact on productivity, initially due to the
obvious factors outlined above and ultimately circumstances such
as reduced costs due to effective reductions in worker's
compensation insurance costs, public liability insurance costs,
hospital operating costs and legal fees associated with permanent
disability claims.
The direct cost of worker's compensation claims does not take into
account the indirect or uninsured costs of an accident. The
indirect costs or expenses associated with an accident include:
down time of machinery and equipment, training and re-training of
employees to take over the injured persons duties, loss of orders
due to inability to supply or late delivery, legal costs associated
with civil claims and prosecutions mounted by enforcement
agencies and the cost of any penalties or fines imposed.
Conservative estimates place uninsured, indirect costs of an
accident between 4 and 7 times the insured cost whereas Davis
and Teasedale (1995) suggest the ratio is between 8:1 and 36:1.
The other compelling reason for investigating a work related

accident is to ensure the employer is fulfilling their legal duty of
care obligation. Any employee, their partners, parents, children
and friends have the right to expect the employee to return from
work each day in the same state of health that they were when
they left for work. There is a long established legal duty of care
under common law on an employer to provide a working
environment that will enable this expectation to be attained.

1.2 Who investigates?

Having established that an investigation is desirable, it must then
be determined who is to conduct the investigation. Accident
investigations fall into two main categories, internal and external. A
workplace has no control over external investigations unless it is
one they have commissioned on their own behalf.
An investigator is a facilitator. A person trained to seek out, record,

and report on the circumstances and causal factors, draw
conclusions and make recommendations to reduce the risk of a
recurrence of the circumstances.
If an accident happens at work, regardless of whether a person is

injured or not, there is a strong chance that the employer's duty of
care to provide a safe workplace, free of hazards, has broken
down. For this reason alone, regardless of any other reasons, the
employer should investigate the accident to establish and eliminate
the hazard and the associated risk that ultimately caused the
accident.
1.3 Internal investigations

The workplace should have a competent, trained person who is
delegated to manage safety at the workplace, and included in this
delegation should be a requirement to investigate all accidents and
incidents. In addition to this employer nominated safety officer, it is
highly desirable to have an elected health and safety
representative, elected by workers at the workplace, as prescribed
in the majority of OHS legislation, who also should investigate and
prepare a report on the accident or incident.
These reports, together with enterprise accident and incident

statistics, should be reviewed at regular safety committee
meetings, where additional comments, ideas and expertise may
throw fresh light on causal factors or preventative strategies.

1.4 External investigations

Depending on the seriousness of the accident or the injuries
received, an investigation may be carried out by many various
investigators apart from any investigation carried out internally by
the enterprise.
The first type of external investigator that may be encountered is

one representing a Statutory Authority. That is a person
representing a Government Agency which administers legislation
which embraces the activity being undertaken at the workplace
involved. This investigator may represent the Coroner or Police
Service if the injured person dies, a health and safety enforcement
agency (WorkSafe WA, Comcare, Bureau of Air Safety, etc.), or a
public utility (fire service, electricity, gas or water). These
investigators have a legal right to be at the premises to interview
witnesses, collect evidence and in some cases stop the work
process.
The next type of external investigator that may be encountered is

private inquiry agents or consultants. These investigators are
normally commissioned to undertake an investigation by an
insurance company representing the worker's compensation
insurer, the public liability insurer of the employer or the public
liability insurers of plant or equipment involved in the accident.
These investigators do not have the same, or any, legal rights as
those representing a statutory authority. This type of investigation
is normally only undertaken where it appears that the injured
person may have suffered an injury that will result in some form of
permanent disability that may result in civil litigation, or where
there has been substantial damage to plant, equipment or property
that may also result in civil litigation.
Once again these investigators do not have the same rights as

investigators from a statutory authority. They do, however, have
some rights under discovery provisions of the legal system.
Employers should refer these matters to their legal representative
or insurance company.
If the injured person was employed by a Government authority, or

if a statutory authority investigated and reported on the incident,
there may be some access to these documents by members of the
public and interested parties nominated above, or indeed any
person, under the provisions of Freedom of Information legislation.

1.5 When to investigate accidents

The ideal time to investigate accidents is now! As close as
possible to the time of the accident is the most desirable, before
evidence starts to deteriorate. Obviously the physical location of
the accident site compared to the location of the investigator will
have a significant bearing on how quickly an accident or incident
investigation will commence. Preferably the investigator should be
one of the first people on the scene, to enable the scene to be
secured and evidence preserved or captured.
If the investigator cannot get to the accident scene immediately,

they should arrange with some other responsible person to secure
the scene and protect the evidence. Depending on the time lapse
between the incident and the commencement of the investigation,
it may be desirable to have another person take photographs if
practicable and prepare a list of persons who were at or near the
scene, who may be potential witnesses.
The deterioration of evidence can take many forms such as

deterioration due to weather conditions (wind, rain, temperature
etc.), destruction or relocation due to the need to remove the
evidence to rescue an injured person, destruction due to
unauthorised persons or vehicles moving around the immediate
vicinity; and the most fragile of all evidence, the recollection of the
human mind and the ability of a persons sub-conscious memory to
fill in gaps in what they saw or their own visual experience being
corrupted by another person's verbal description of what
happened. These factors will be discussed further in the
investigation phase.

Section 2: THE INVESTIGATION
An investigation is a methodical, systematic, unemotional

undertaking to collect and interpret information about an event to
establish the extent of an injury or loss, why it happened and to
analyse the processes involved to minimise the risk or prevent a
recurrence. The investigation will normally result in the preparation
of a logical, sequential report of the events with recommended
preventative strategies.
2.1 Pre-planning
The amount of pre-planning required is dependent on the number
and type of discreet workplaces the investigator is likely to be
called to, and their geographical location. A major need for pre-
planning is to enable an investigator to reach an investigation site
as soon as possible after the event and to have all of the
equipment required to conduct the investigation at their disposal.
If a person such as a health and safety representative is only

responsible for investigating accidents in their immediate
workplace or location within the workplace, their pre-planning will
probably only require adequate stationery to be physically at hand,
together with a written list of where all other items that may be
required, can be located.
On the other hand, if an enterprise group safety officer has

workplaces that are spread throughout the State or Country they
would need to have a fully equipped case, bag or other container
ready to go at any time. The amount of equipment to be taken will
depend on the mode of transport to be utilised (e.g. motor vehicle
or aircraft). This situation is the scenario faced by most external
investigators.

Basic equipment that may be required includes:
 mobile telephone with back-up power pack, for communication;

 camera, with spare film, flash and batteries;
 personal protective equipment (safety glasses, hard hat, safety
shoes, hearing protection, gloves, respiratory protection, wet
weather gear);
 recording equipment, with spare tapes, batteries;
 stationery, writing/sketching materials, pre-printed forms,
handouts;
 containers for taking and storing samples; and
 small hand tools, torch, pliers, screwdriver, tape measure.
Other items that may need addressing are transport,

accommodation and expenses.
If a motor vehicle is to be the chosen form of transport, particularly

to distant or remote locations, the vehicle should be suitable for
that task and ready for use (fuel, roadworthiness,
maps/directories). If an aircraft is to be used, bookings are
required, transport at the destination arranged, accommodation
booked, etc, as well as financial arrangements for paying for these
services (cash advance, company credit card, purchase order
book).
2.2 Commencing the investigation

The investigation involves the collection of evidence some of it
extremely fragile, consequently it is highly desirable to collect the
evidence in descending order of fragility. Fragility of evidence can
be described as breakage, distortion or loss which makes the
evidence unusable. One of the most fragile pieces of evidence is
the recollection of a witness, as this can change with time,
particularly when their sub-conscious memory starts to fill in the
events they saw with what other people have stated they saw or
even theorised what might have happened.

The rescue of an injured person and securing the accident scene

from contamination by other people moving around the area is of
the highest priority. It may be necessary to make the scene safe
before attempting to commence first aid on an injured person.
Once the injured person has been treated and removed then the
scene should be secured to ensure the safety of yourself and other
persons from any hazards that may still exist, and to restrict
access to the scene so as to leave it as close as possible to the
conditions existing at the time of the accident.
If it is necessary to disturb the site to either remove the injured

person or to secure any hazards, take a video tape recording or
photographs if practicable. Alternatively make a note or sketch of
what is done or what the scene looked like prior to the changes, as
soon as possible.
2.3 Examination
Overview or preliminary investigation
During the preliminary investigation an overview of the events is
obtained. It is a sound practice to make brief written notes on what
steps you have taken and when, and who you speak to and what
information they can contribute. The investigator then has a
chronological list of actions taken which will enable prioritising
further actions, particularly which witnesses to interview and in
what order.
The overview phase allows the investigator to get a feel of the

workplace, what they do, what they produce, a broad picture of the
workplace, the macro view. It enables the investigator to locate the
accident scene in the overall plan of things and where this scene is
located in the process. Depending on the size of the workplace,
this broader macro view is invariably the extent of working
knowledge of the workplace by some senior management.

Accident scene
The investigator then turns their attention to the smaller, more
confined accident scene. This zone is where a lot of the physical
evidence will be located, and this is the area that should be
secured and preserved immediately.
On arriving at the accident scene it is essential that the investigator

makes an assessment of any hazards that may be present, either
the pre-existing cause or hazards that have arisen as a result of
the accident that could cause further injury or harm. These
hazards should be eliminated, controlled or managed so as not to
place any other person at risk.
At this stage it is desirable to take photographs of the accident

scene, a video recording if equipment is available and sketches or
notes about the site. It may be that items, plant or equipment
which were not originally thought to be involved in the accident,
subsequently are identified to have had a contributory effect. A
visual image will record all items and their location relative to each
other and the immediate accident site.
Witnesses
A witness is a person who has first hand knowledge of some fact related,
directly or indirectly, to an accident or incident.
The next step is to identify and speak to witnesses, initially briefly,

to ascertain what information they can contribute to the actual
event and the normal procedures that were in place. As each
factor is identified, appropriate photographs, samples and
sketches should be taken or made, together with a notation of the
time this was done.
From this list of witnesses the investigator needs to prioritise the

order in which to interview them, taking into account the fragility of
their evidence, and commencing with eye witnesses to the event
or accident. People who can only advise on the usual work
practice or procedure would receive a much lower priority.

The investigator then needs to determine the method of recording

what the witness has to say. This will be strongly influenced by the
type of investigation being undertaken. If the investigation is being
undertaken by a statutory authority, it is highly likely that they will
insist on a written, signed statement or a record of interview which
is initially taped and then transcribed into a written format. This
requirement is necessary to preserve the evidence in a permanent
record for reporting to other authorities, and for evidence for legal
purposes if deemed necessary. The main advantage of a record of
interview that is taped is that you have a verbatim record of what a
person said - not what you thought they said.
When taping a record of interview it is important to record on the

tape the time the interview starts and finishes and the time any
interruptions take place. The reason for recording the time is to
have a permanent record of the time it took to record the interview
which can be used to prove that nothing has been added to, or
deleted from, the recorded interview.
Inquiry agents will also take some written statements, once again
for future legal processes if they are commenced.
In other circumstances the investigator may prefer to make notes

of what is said, the ultimate objective is to have a written record of
all the facts so that a word picture can be prepared of all events
leading up to and including the incident or accident, which can
then be presented in a report. Evidence that is collaborated can be
recorded in confidence. Uncorroborated evidence needs to be
treated with caution, although not discounted unless collaborated
evidence refutes it.
Apart from an accident victim, people rarely observe the full

circumstances of an accident or incident and not being trained
observers rarely see in detail what they are looking at and even if
they do, they cannot remember the detail. The investigator will
need to ask appropriate questions in order to obtain relevant
answers. The investigator should attempt to gain rapport with the
witness. It is a good idea to commence with some general
conversation to relax the person and give them confidence in
replying to questions, for example, conversation about their own
job, their own list of duties and generic questions about the
workplace.

The investigator also has to be extremely careful not to influence

the witness by the type of questions they ask, any mannerisms
they may display, or any reactions to questions that may give the
impression of the type of answers they should give.
In the preliminary overview of the accident scene and discussions

with potential witnesses, the investigator should be developing a
clear picture of the process that was taking place before and
leading up to the accident or incident. If any gaps appear in the
picture the investigator can then formulate meaningful questions to
elicit information from the witnesses.
Whilst an interview is in progress a witness may provide

information that has not previously been identified or recorded as
part of the process or equipment involved in the accident or
incident. It may be necessary, as a result of this new information,
to change or add to the questions being asked, and in some
cases, re-interview persons who have already been interviewed.
A recorded witness statement, either in writing or electronically,

should be considered as a confidential communication between
two people, and as such, this confidentiality should be respected. It
is perfectly acceptable to use the information gleaned in the
interview in any subsequent report, however the copies of the
person's statement should not be given to a third party without
firstly obtaining the permission of the witness.
Evidence and exhibits

What is the difference between evidence and exhibits? Raymond
Kuhlman in his publication Professional Accident Investigation
categorises evidence into four categories in descending order of
fragility as:
 People;
 Positions;
 Parts; and
 Papers
Exhibits are physical evidence which can be used in a Court of

Law.

People provide eye or ear evidence relating to events prior to,

during and after the accident. This information is recorded as
witness statements as described above.
Positions are the physical location of people and parts prior to, at
the time and after the accident. The position of parts after the
accident can be extremely fragile, particularly if they are removed
or repositioned during recovery of an injured person, or
accidentally due to the site not being adequately secured. To
ascertain the position of people and parts prior to and at the time
of an accident will normally depend on the affirmation of witnesses.
Parts are visible, tangible, material pieces of plant, tools,

equipment, buildings at or around the accident scene that may or
may not have had some influence prior to, during or after the
accident. The examination and inspection of parts that are
suspected of having caused an accident through distortion or
failure may be required to be undertaken by a person who is
appropriately qualified to examine the part, or has sophisticated
equipment required to undertake comprehensive testing. Any
reports or advice provided will form part of the evidence in the
investigation and the person who provides the advice or
information are usually known as an "Expert Witness."
Papers are the most stable, durable part of evidence. They take
numerous forms and consist of written records such as: job
standards, job procedures, operating instructions, maintenance
manuals, maintenance records, induction records, training records,
qualifications of personnel, certificates of competency, contracts
and quotes.

Section 3: RESEARCH
3.1 Determine existing work

procedures
The research phase of determining existing work procedures is
normally undertaken at the workplace itself, although where an
enterprise has more than one workplace, written procedures may
be located at the head office. Where written procedures are
available, a copy should be obtained and the contents should be
compared with the verbal descriptions supplied by persons,
including the victim, who have performed the duties or functions, or
undertaken the process that was involved in the accident.
These procedures can be analysed to determine any weaknesses

in the system, and compared with similar procedures at kindred
industries.
3.2 Check for similar accidents

Numerous statutory authorities throughout the world produce
executive summaries of accident reports. These are known by a
variety of names such as safety alert, safety information,
significant incident reports and significant incident summaries.
These are accessible through various mediums such as safety
magazines, trade and business journals, direct mailing lists, health
and safety libraries and of course the internet. WorkSafe’s
SafetyLine has one of the best on-line collections of summaries.
The disturbing aspect of reading these summaries is that the same

type of accidents are happening all around the world, time after
time, indicating that people are not learning from accidents in
which some people have been seriously injured or even died.
On the positive side, the accident that the investigator is examining

is probably not unique. With a little research it is probable they will
locate other accidents that have taken place in very similar
circumstances. By researching these other accidents the
investigator will be able to benefit from other investigators'
research, findings, recommendations and preventative strategies.

Some investigators attempt to reconstruct the circumstances of the

accident. This is not a recommended practice as reconstruction
goes hand in hand with recurrence. At this stage it is important to
recognise that there is a distinct difference between reconstruction
and re-enactment.
Reconstruction is a rebuilding of the accident and is primarily used

to establish the sequence and reason parts and equipment failed.
Re-enactment is description of events played out, primarily to
obtain time-frames and sequences of events prior to the actual
incident or accident. Reconstruction can be an extremely important
tool, particularly when there are no witnesses to the event and
there is minimal or no physical evidence. Where reconstruction of
the circumstances or part of the circumstances are deemed
necessary, it must be made in a controlled environment.
3.3 Other research

Research is not confined to existing work procedures and similar
accidents. It may be associated with establishing methods of
eliminating a hazard, reducing the risk of the hazard, substitutes
for the hazard, or may relate to preventative methods or strategies.
Research may be undertaken to establish the strength of tools and

equipment, effects of exposure to unseen hazards such as gasses
or electrically induced magnetic fields, remember, all hazards are
not necessarily visible or can be smelt.
The best place to start research is in a library, either physical or

electronic. You are currently operating in the largest resource
“library” in the world - the information super highway - the Internet.

Section 4: ANALYSIS
“Accident investigation is like peeling an onion. Beneath one layer

of causes there are other layers. The outer layers deal with the
immediate causes while the inner layers are concerned with the
underlying causes such as weakness in the management system.”
Trevor Kletz - Learning from Accidents in Industry
4.1 Determine immediate causes

The immediate causes are normally the easiest to ascertain, and it
is essential to establish these to determine any underlying causes.
They provide a starting point for the investigation. The immediate
causes will be the details immediately provided by people,
positions and parts. There will usually be tangible evidence
Most of the immediate causes will be established in the early

stages of the investigation when the investigator is gathering
preliminary information, taking photographs, identifying witnesses
and what they can contribute to the investigation. The information
will be gathered from people, position and parts. Paperwork
invariably will not provide information on the immediate cause of
accidents.
Witnesses will provide most of the detail of the immediate causes

with minimal prompting or questioning, particularly when they are
interviewed within a close time frame to the event. Some
prompting may be necessary to obtain confirmation of points
raised by another witness, however, it is essential that the
investigator avoids leading the witness.

4.2 Determine underlying causes

The determination of the underlying causes will be dependent on
the immediate causes supported by information provided by
witnesses and established by undertaking appropriate research.
The immediate causes have told us how the accident happened,
whilst the underlying causes will tell us why the accident
happened.
To establish the underlying causes the investigators will need to

ask probing questions of witnesses, primarily to establish their
understanding of the health and safety practices and procedures in
place at this site, and whether they are being implemented and
adhered to. Some of the witnesses the investigator will need to
interview will not have first hand knowledge of the accident that is
being investigated but should be fully aware of the health and
safety practices and procedures of the enterprise
Major writers on accident investigation such as Trevor Kletz,

quoted at the start of this section, all agree that the responsibility
for the basic underlying causes of accidents rests with
management. DuPont, one of the worlds largest enterprises and
manufacturers, espouses, amongst other things, the theory that:
".....all injuries are preventable and are ultimately caused by
management failure."
This does not mean that management have deliberately created

situations where a person will be injured, but, usually they have not
fulfilled their duty of care, for example: to provide sufficient safe
working procedures or policies that will identify the hazard before
the risk associated with that hazard becomes unacceptable; or to
provide and enforce sufficient maintenance and replacement
policies to prevent a piece of equipment becoming distorted or
failing.

Take an example of a person being injured because a rope or

cable used to lift or restrain some load or item, fails, causing the
injured person to be struck by the load or item. The immediate
cause of the accident is that a rope or cable failed. It broke! The
important thing to establish is why did it break. Was there a
procedure in place to regularly check the rope or cable for wear?
Was there a procedure in place to replace the rope or cable after a
pre-described period of time or usage? If not, management have
failed in their duty of care! We all know that ropes and cables are
disposable or consumable items that are subject to wear and tear
and there should have been inspection, maintenance and
replacement procedures in place.
If our research reveals that the inspection, maintenance and

replacement procedures were in place, what do we do? The next
step is to establish were these procedures observed? Did the
person who was responsible for implementing these procedures
know about the procedures and their role? Have they been trained
to assess the conditions of the rope or cable? If not, management
have failed to provide adequate training to ensure that their
employees work in a safe environment!
Our further research indicates the procedures were in place, the

person responsible for implementing the procedures was fully
aware of their responsibilities and had received adequate training
and were competent to carry out the tasks. Ah-ha! The careless
worker! WRONG! Management failure again! Lack of
supervision. It is fine to delegate a responsibility after ascertaining
the delegated person is adequately trained and skilled. However it
is essential that adequate follow up is maintained to ensure these
delegated responsibilities are implemented and continued.
Once again, our research has ruled out all of these factors. The
cable was inspected, maintained and was not due for replacement.
What next? Was the rope or cable adequate for the purpose it was
being used? Was the rope or cable for industrial use? Was the
rope or cable quality tested? Was the load excessive? These are
the type of questions that have to be asked, the type of research
that has to be undertaken, in a methodical structured format,
eliminating potential for failure as you go, until you find the root
cause of the accident.

Hopefully, by now, you will see a trend. All of the scenarios

outlined in the example all ultimately pointed to a management
failure. Failure to have safe working procedures! Failure to have
adequate training for employees! Failure to have adequate
instructions for employees! Failure to have adequate supervision
for employees.
Whilst in some accidents the employee may have done the wrong
thing, and admits it, it still does not absolve management from
having sufficient systems, training, instruction and supervision in
place that should have detected and prevented the employee
doing the wrong thing.
Whilst undertaking the research and analysis of the immediate and

underlying causal factors of this scenario, the investigator should
have been cognisant that they have to make recommendations
and provide preventative strategies as part of their investigations
and reporting, as well as being mindful of the hierarchy of control.
Could the system have been changed to avoid using the rope or
cable? Could the rope or cable be substituted with another method
of restraint or lifting? Was it necessary to restrain or shift this item
or load? Was it necessary for the injured person to be in a position
where they could be struck by the load if the rope or cable failed?
Could a barrier be placed between the load and the location of the
injured person?

Section 5: REPORTING
An accident report provides a condensed formal record of facts

and recommendations surrounding an accident, giving each level
of management information with which to decide and prioritise
remedial action.
The investigator's memory, like that of a witness, is fragile and will

tend to sub-consciously fill in gaps where no evidence exists: it is a
peculiarity of the human mind. The investigator does have the
advantage of photographs, evidence, exhibits, notes taken at the
time and statements to refer to which will refresh their memory,
however the best approach is to prepare a written report as soon
as possible, preferably before they get involved in another
investigation. Remember the old adage:
"The job's not done until the paperwork is finished."
5.1 Preparation of report

When preparing a report the author, in this case the investigator,
must assume the reader does not have any knowledge about the
workplace or the work practices. Indeed they may not have
knowledge of safe work practices. Every aspect will need to be
spelt out, in a concise format, being careful not to become
verbose.
The report, like the investigation, also needs to be a methodical,

systematic, unemotional record of the facts and events that led to
an accident, description of evidence and exhibits collected,
together with an analysis of the causal factors and
recommendations for preventative strategies. Remember there
must be a beneficial outcome for the resources expended on the
investigation.

The depth of the report, the analysis of the causal factors and
recommendations will be influenced by the seriousness of the
accident, the extent of the injuries received and what type of
investigation is being undertaken, by whom and for what purpose.
An internal investigation will be looking primarily at developing
preventative strategies, whereas an investigation by a statutory
authority will probably be looking at breaches of legislation, and
will be less influenced by the seriousness of the injury but more by
the extent of any breach of legislation.
5.2 Format of report

The report should contain sufficient information to enable a
decision maker to act on the investigator's recommendations. Be
aware that any modification or change to equipment, work
procedures etc., will cost money, consequently cost benefit factors
should be included with recommendations, in an internal
investigation report. The report should commence with a brief
overview of the accident, when, where, what and to whom,
followed by a broader outline of the workplace, the work being
undertaken at the time of the accident and the events leading up to
the accident. These headings will probably be fairly common to all
investigations.
The format of the body of the report will depend on the

circumstances of the accident, and will normally address issues
such as: the qualifications or training of the injured person, the
suitability or condition of any plant or equipment involved in the
event, the contributory influence, actions or failures of other
persons which may have led to the accident and perhaps other
physical factors such as weather, lighting, time of day, length of
work shift, working conditions, housekeeping, etc, which also may
have had some influence, or which can be discounted as having
an influence. For example: The weather was fine with light breezes
and moderate temperature which would have had no influence on
this accident. It is better to make a brief statement like this than to
have the reader wondering if the weather was an influence and if
the investigator overlooked this matter or just failed to comment on
it.

Photographs and sketches should be strategically located

throughout the text to enable easy reference and access by the
reader. Other relevant documents collected during the
investigation and research phases should be included as
attachments, clearly labelled and included in a contents page as
well as being referenced at the appropriate part in the body of the
report.
The report will conclude with comments or discussion of issues

that have arisen or need to be addressed, the conclusions reached
by the investigator together with appropriate recommendations
including preventative strategies from the investigator. Without this
step the whole investigation and report have been a complete
waste of time.
5.3 Distribution and use of report

The distribution and use of an accident or incident report will
depend on, to some extent, who prepares the report and for what
reason.
At the workplace level, the report is likely to be prepared by a

safety officer or person delegated to manage safety, together with
a report from the elected worker health and safety representative
(if any). This report may be a joint report between these two
parties.
The report should be submitted to the enterprise management

through their normal reporting channels, for information and action,
to act on or authorise any recommendations contained within the
report. The report should also be forwarded to the health and
safety committee, if one exists, to form part of the agenda and
discussions for the next scheduled meeting. If the accident was so
severe or the hazards exposed so intolerable, it may be necessary
to convene a special meeting of the health and safety committee to
address the matters raised or recommendations made.

The health and safety committee is an appropriate forum for

members to discuss the report, the circumstances described in the
report, the outcomes and the recommendations. It may be that the
combined expertise of the committee will provide alternative,
perhaps more practicable solutions or substitutions, to prevent
further occurrences of these circumstances. Pooled resources can
be extremely beneficial, particularly if an enterprise decision maker
is involved in the process. This is also an excellent forum to follow
up and monitor recommendations and preventative strategies, to
ensure they are implemented. When implementation is left to one
person, it is easy for the process to run off the rails if that person is
absent on leave, sick, or leaves the particular work area or the
enterprise. The safety committee will have recorded notes or
minutes to ensure that the recommendations are continuously
reviewed until the matter is satisfactorily completed or resolved.
In the early section of this reading we referred to who conducts an

investigation and further split the options between internal and
external investigators. The external investigators will in most cases
produce a detailed report for the organisation they represent, and if
the person died as a result of the accident, the Coroner will be
seeking a report prepared by a Government agency. If that agency
proceeds to a prosecution for breaches of legislation arising out of
the investigation, a copy will also be forwarded to the Crown
Solicitor.

SUMMARY
Accident investigations are undertaken to establish causal factors

of the event, and the quicker the investigations commences, the
less risk there is of evidence being contaminated and witnesses
descriptions being corrupted. A variety of investigators may be
involved in the investigation of a particular event, and whilst they
may be looking at the event from different perspectives, they all
need to establish the causal factors.
Investigations need to be pre-planned. The investigator should

have all of the tools and equipment that they may require
accessible at short notice, and be prepared to commence an
investigation immediately. When advised of the circumstances of
an accident they should be considering possible scenarios and
tactics so when they reach the investigation site they have some
concept of what avenue they will be following. The investigation is
a methodical examination of the accident site; the physical
evidence of what happened; the people who have first hand
knowledge of facts, related directly or indirectly to the event; and
any records, papers etc that may contribute to the outcomes of the
investigation.
After this examination has been undertaken and photographs

taken, sketches made, witnesses interviewed and exhibits
collected, there will need to be research into: other similar
accidents; existing work practices and procedures; and other
relevant matters. This research will be necessary to establish the
deeper causal factors. When all of this information is available the
investigator will be able to analyse the event to establish causal
factors, for which they will develop preventative strategies to
reduce the risk of a recurrence of the circumstances surrounding
the event.
At the conclusion of these steps it will be necessary for the

investigator to commit their investigation details and conclusions to
writing, in the form of a report of the event, conclusions reached
and recommendations for preventative strategies. This report
should be submitted to the management of the workplace where
the accident happened, the health and safety committee at the
workplace, and depending on who undertakes the investigation
and for what purpose, the party or parties who commissioned the
investigator's investigation.

Depending on the status of the investigator, they may or may not

have any part in the implementation of their recommendations.
The implementation and follow up of recommendations will
normally be the role of the management of the enterprise together
with the health and safety committee and elected worker health
and safety representatives of the workplace.
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Occupational Health & Safety

ACCIDENT INVESTIGATION AND

SECTION 1: GETTING STARTED.................................................................................2

SECTION 2: THE INVESTIGATION ..............................................................................7

SECTION 3: RESEARCH ............................................................................................14

SECTION 5: REPORTING ...........................................................................................20

Government of Western Australia

The SafetyLine Institute material has been prepared

© 2009 State of Western Australia. All rights reserved.

Details of copyright conditions are published at the SafetyLine Institute website.

"An investigation is a search for the truth, in the interests of justice

The objective of this reading is to provide learners with an

 describe the purpose of an accident investigation;

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 1

Section 1: GETTING STARTED

What can we achieve from conducting an accident investigation?

We have already lost enough productivity as a result of the

Interesting and compelling reasons for not conducting an

PAGE 2 SAFETYLINE INSTITUTE JANUARY 2009

1.1 Why investigate?

The reduction of lost time injuries in a workplace, industry, State or

The other compelling reason for investigating a work related

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 3

1.2 Who investigates?

An investigator is a facilitator. A person trained to seek out, record,

If an accident happens at work, regardless of whether a person is

1.3 Internal investigations

These reports, together with enterprise accident and incident

PAGE 4 SAFETYLINE INSTITUTE JANUARY 2009

1.4 External investigations

The first type of external investigator that may be encountered is

The next type of external investigator that may be encountered is

Once again these investigators do not have the same rights as

If the injured person was employed by a Government authority, or

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 5

1.5 When to investigate accidents

If the investigator cannot get to the accident scene immediately,

The deterioration of evidence can take many forms such as

PAGE 6 SAFETYLINE INSTITUTE JANUARY 2009

Section 2: THE INVESTIGATION

An investigation is a methodical, systematic, unemotional

If a person such as a health and safety representative is only

On the other hand, if an enterprise group safety officer has

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 7

Basic equipment that may be required includes:

 mobile telephone with back-up power pack, for communication;

Other items that may need addressing are transport,

If a motor vehicle is to be the chosen form of transport, particularly

2.2 Commencing the investigation

PAGE 8 SAFETYLINE INSTITUTE JANUARY 2009

The rescue of an injured person and securing the accident scene

If it is necessary to disturb the site to either remove the injured

The overview phase allows the investigator to get a feel of the

JANUARY 2009 SAFETYLINE INSTITUTE PAGE 9

On arriving at the accident scene it is essential that the investigator

At this stage it is desirable to take photographs of the accident

The next step is to identify and speak to witnesses, initially briefly,

From this list of witnesses the investigator needs to prioritise the

PAGE 10 SAFETYLINE INSTITUTE JANUARY 2009

The investigator then needs to determine the method of recording

When taping a record of interview it is important to record on the

In other circumstances the investigator may prefer to make notes

Apart from an accident victim, people rarely observe the full