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Causation, Reporting
& Investigation
Causation Theories

Single Cause Domino Theory

Multiple Causation
Single Cause Domino
Heinrichs theory
Each factor is the fault of the
factor that immediately precedes it
A preventable injury is the natural
culmination of a series of events or
circumstances, which occur in a
fixed logical order
Single Cause Domino

Ancestry & Social Fault of Person Unsafe Act or Accident Injury

Environment Condition
Single Cause Domino
If one of the dominoes is
removed then the chain of
events will be halted, and the
accident will not happen
Element 3 (unsafe act and/or
mechanical or physical hazard)
is probably the easiest factor to
Single Cause Domino
Bird & Loftus extended Heinrichs theory to encompass
the influence of management in the cause & effect of
They suggested a modified sequence as follows:
Lack of management control, permitting
Basic causes (personal & job factors), leading to
Immediate causes (substandard practices or conditions), which
are the direct cause of
The accident, which results in
Loss (negligible, minor, serious or catastrophic
This modified sequence can be applied to every
accident and is of basic importance to loss control
Multiple Causation

May be more than one cause, not only in

sequence, but occurring at the same time
In accident investigation all causes must
be identified
Usually simple accidents have a single
Major disasters normally have multiple
Multiple Causation

Cause a

Cause b Unsafe Act

Cause c

Injury or

Cause d

Cause e

Cause f
Unsafe Acts

Operating without clearance
Operating at unsafe speed
Rendering safety devices inoperative
Using unsafe equipment, or using it unsafely
Unsafe methods e.g. loading, carrying, mixing
Adopting unsafe position or posture
Working on moving or dangerous equipment
Horseplay e.g. distracting, teasing, startling
Failure to wear PPE
Lack of concentration; fatigue or ill health
Human Factors
Unsafe Acts

Unsafe acts can be active or passive:

Active Unsafe Acts:
Worker deliberately removes machine guard
Passive Unsafe Acts:
More difficult to deal with
By pursuing an active safety policy, it is
possible to achieve a reduction in bad habit s
and hence accidents
Unsafe Conditions

Inadequate guarding
Unguarded machinery
Defective, rough, sharp, slippery, decayed, cracked surfaces
Unsafely designed equipment
Poor housekeeping, congestion
Inadequate lighting, glare, reflections
Inadequate ventilation, contaminated air
Unsafe clothing or PPE
Unsafe processes
Hot, humid or noisy environment
Unsafe Acts/Conditions

The picture shows how unsafe acts & conditions may interact
to produce an accident. Accident potential is increased when
unsafe acts & conditions occur simultaneously. Of course, this
is not to say that an act or condition alone could not result in
an accident.

Unsafe Acts Unsafe
Accident Reporting

Information should be kept for

all injuries, and preferably for
near misses
The safety practitioner needs to
design a suitable form to ensure
that he gets the information
that he needs for investigations
Accident Investigation
Name & personal details of victim
Date, day and time of accident
Location of accident
Occupation of victim
Job being done at time
Nature of injury or damage
What inflicted the injury or damage
Who had control of the cause of the injury or damage
What actually happened
Basic and immediate causes
Immediate remedial action taken
Recommendations to prevent recurrence
Use of Investigation
Accident records are useless if they are used only to count
accidents. Detailed and thorough study of the records as part
of the normal ongoing accident prevention programme should
yield the following useful information:
Relative importance of the various injury & damage sources
Conditions, processes, machines and activities which cause the
The extent of repetition of each type of injury or accident in each
Accident repeaters, I.e. those workers who tend to be repeatedly
injured or are involved in more accidents
How to prevent similar accidents in future
Accident Investigation

Could be carried out by:

Safety Practitioner
Management or Supervisor
Safety Representative
A joint investigation by company/safety rep is often a
good idea
An investigation which does not discover what went
wrong, and produce some useful information and
recommendations for corrective action, is just a
waste of time
Accident Investigation

Initial Actions
Questioning the victim
Treatment of victim is first priority
Immediate questioning may not be possible - they should be
allowed to collect their thoughts and control their nerves
Witnesses & Conditions
Investigator can usually go to accident scene and get a fairly
complete story from on-site conditions and witnesses
In all serious accidents and in all other cases where
practicable, conditions at accident scene should remain
undisturbed until investigation is complete

Immediate supervisor:
Likely to know most about the situation
Knows his own people better than anyone
Has personal interest in determining
causes, as accidents affect the efficiency
and morale of his department
Familiarity with staff could cause

Recognising Hazards
Familiarity with plant, equipment and layout of operations
will assist in recognising hazards that have been overlooked
for some time
Unsafe acts, as well as conditions, contribute towards most
It is not sufficient merely to recommend fitting a guard while
overlooking the unsafe act, such as rendering the guard
ineffective or placing hands in the danger zone
It is also insufficient to limit attention to an unsafe act if
fitting a better guard would reduce the likelihood of injury

Safety Practitioner
Necessary in more serious cases
Supervisor may not have necessary
Should seek assistance from local
Investigator must have authority to
go as far as is necessary to get to
the cause of the problem
The Investigation

As soon as possible after the event
Facts will be easier to determine and more
details will be remembered by those involved
Helpful if investigator is present during the fire
Investigator may gain useful information by
watching the activities of firemen
The Investigation

Depending on severity of any injuries or
damage, investigator should be present
during clear-up and reinstatement as
valuable clues may otherwise be missed
Failing which, supervisor should take it
upon himself to collect the necessary
The Investigation

Photographic equipment
Portable lights (electricity may be switched off or accident
scene may be poorly lit)
Sketchpad, pencils and measuring equipment
Record-keeping equipment e.g. notebook and cassette
Sample collection equipment e.g. jars, paper bags, cartons
Tools for cleaning debris or spillages should also be available
Portable gas/vapour detecting equipment
Accident Investigation
1. Inspection of the accident scene to collect any
information relating to physical conditions of the
plant, equipment and building
2. Interview witnesses and others likely to give
information concerning any unsafe acts or
conditions which may have contributed to the
3. Summarise all available evidence accurately in a
written report to management, recommending
future actions to prevent a recurrence
Inspection of the Scene

Careful, detailed look at accident scene, evaluating and

noting the following:
Extent & severity of damage
Damage to surrounding property
Environmental conditions which may have had some
bearing on the accident, such as temperature,
ventilation, humidity and illumination
Survey the accident scene to see if there are any
obvious dangerous physical conditions which may have
been responsible for the accident
Inspection of the Scene

In the case of spillages, splashes or other escapes

of poisonous, explosive, flammable or other
dangerous material, it may be necessary to take
samples for subsequent investigation
Where machinery or other equipment has been
involved, it may be necessary to issue instructions
prohibiting the use or repair of it until the
investigation has been completed
Talking with On-Site
Easy to upset people when asking questions about
what has been done, or what has not been done
Casual remarks made during the site inspection
may be quite revealing and the investigator should
continue to talk to any personnel involved near the
scene of the accident
This would also serve as an ideal opportunity to
explain the object of the exercise is to discover and
root out the causes so as to prevent a repetition. It
is not to apportion blame or to criticise any
Interviewing Witnesses

Types of Witness
Primary witness
The victim
Secondary witness
Extremely rare, the eyewitness
How many people really see the instant of an accident?
Tertiary witness
Can offer variety of corroborative statements regarding
the acts of people or environmental
Interviewing Witnesses

Putting witnesses at ease

Explain fully purpose of investigation
Encourage participation and involvement
Show interest in any ideas they might have
about possible preventive measures
Witness must be assured that the purpose of the
investigation is not to blame anyone, but to
attempt to find out the cause and thereby reduce
possibility of a recurrence
Interviewing Witnesses

Interview Location
Best to carry out interviews at scene of
accident, as it is easier for those involved
to communicate effectively with props
close to hand
Easier to explain what happened if
witnesses are able to point out specific
things and recall their actions related to
specific locations
Interviewing Witnesses

Question Phrasing
Open ended question - what, where, when, how or
Questions starting with why may put witness on the
Typical questions:
What happened? What did you see?What time was it?
Where were you at the time? Where was the victim?
When did you realise something was wrong?
How did it happen? How were you involved?
How could it have been prevented?
Who else was involved? Who else saw it? Who reported it?
Interviewing Witnesses

What happened will often promote the fullest response
and it is vital the investigator listens, without interruption,
to the witnesss account of the accident
If something is not understood, investigator should wait
until witness has completed his account before asking for
Do not disagree with any of witnesss statement or make
any judgements on his evidence alone
What a witness believes to have happened will depend to
some extent on just how he perceived the situation, even
though this might conflict with the actual facts
Interviewing Witnesses

When witnesss account of accident has been
heard, investigator should repeat it to witness to
ensure account is fully understood
Interview should be concluded on a positive note,
which is best achieved by discussing any ideas he
may have regarding prevention of a similar
occurrence - this will serve to reaffirm the purpose
of the interview and ensure the witnesss further
co-operation, should it be needed
Interviewing the Victim

Ideally first to be interviewed

Injuries may be serious, or may
be suffering from shock
Should be interviewed at the
earliest opportunity
General principles for
interviewing witnesses apply
What Should be
ALL incidents/accidents should be
Purpose is to find the cause, with the
intention of preventing a recurrence,
rather than apportioning blame
An injury usually involves some degree of
blame falling on management,
supervision, victim or workers