Conducting
an Accident Investigation
Course 102
Safety Certified Supervisor Series
MODULE 4: ANALYZING THE ACCIDENT PROCESS
Paint a word picture
It's important that the sequence
of events clearly describe what occurred so that someone unfamiliar with an
accident is able to "see it happen" as they read. If an event is
hard to understand, it may be that the description is too vague or general.
The solution to this problem is to increase the detail by:
- Determine if anything else was
said/done before or after the event you are currently assessing.
- Separate actors. Remember, an
actor may be a person or a thing accomplishing a given action. If an event
includes actions by more than one actor, break the event down into two events.
To get a good idea what the sequence of events looks like, review the example
below that was prepared for an actual fatality investigation conducted by
OSHA a few years ago.
Sequence of Events
- Employee #1 returned to work
at 12:30 PM after lunch to continue laying irrigation pipes.
- At approximately 12:45 PM
employee #1 began dumping accumulated sand from an irrigation mainline
pipe.
- Employee #1 oriented the pipe
vertically and it contacted a high voltage power line directly over the
work area.
- Employee #2 heard a 'zap'
and turned to see the mainline pipe falling and employee #1 falling into
an irrigation ditch.
- Employee #2 ran to employee
#1 and pulled him from the irrigation ditch, laid him on his back and
ran about 600 ft to his truck and placed a call for help on his mobile
phone.
- Employee #2 than ran back
to find employee #1 had fallen back into the ditch.
- Employee #2 jumped back into
the ditch and held employee #1 out of the water until help arrived.
- Two other ranch employees
arrived and assisted employee #2 in getting employee #1 out of the ditch.
- Approximately one minute later,
paramedics arrived and began to administer CPR on employee #1. They also
used a heart defibrillation machine in an attempt to stabilize employee
#1's heart beat.
- At approximately 1:10 PM an
ambulance arrived and transported employee #1 to the hospital where he
was pronounced dead at 1:30 PM.
This example is rather brief and
there may be other related events that indirectly contributed to the accident.
However, it does give you sufficient descriptive detail to paint a mental
picture of the actors and acts that occurred immediately prior to and including
the accident.