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:

  1. Determine if anything else was said/done before or after the event you are currently assessing.
  2. 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

    1. Employee #1 returned to work at 12:30 PM after lunch to continue laying irrigation pipes.
    2. At approximately 12:45 PM employee #1 began dumping accumulated sand from an irrigation mainline pipe.
    3. Employee #1 oriented the pipe vertically and it contacted a high voltage power line directly over the work area.
    4. Employee #2 heard a 'zap' and turned to see the mainline pipe falling and employee #1 falling into an irrigation ditch.
    5. 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.
    6. Employee #2 than ran back to find employee #1 had fallen back into the ditch.
    7. Employee #2 jumped back into the ditch and held employee #1 out of the water until help arrived.
    8. Two other ranch employees arrived and assisted employee #2 in getting employee #1 out of the ditch.
    9. 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.
    10. 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.

 

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