An accident investigation is a concentrated effort to establish all pertinent facts and opinions regarding how and why an accident developed. Naturally, information is obtained from all available sources by considering the elements of the accident: how, who, when, where, and why. The facts, as gathered, are evaluated as to their soundness and feasibility. A report of the accident is then submitted with the investigator's judgment of what happened, how it happened, why it happened, and what must be done to prevent similar accidents in the future.

Purpose of an Accident Investigation

There are two mistaken viewpoints of the purpose of an accident investigation that need to be explored. The first opinion sees the investigation as a means of completing an accident report form. This opinion downgrades the investigation to a superficial action, and any information gathered is usually just enough to complete the form and, therefore, serves no useful purpose to anyone. The second mistaken opinion is that the accident investigation is merely one to find who is to blame. The irony of this opinion is that, usually, the injured man is to blame for the accident, and nothing constructive develops from an investigation of this nature.

The constructive and only real purpose of an accident investigation is to establish all pertinent facts and opinions in order to establish how and why an accident occurred in order that constructive conclusions can be made to prevent a recurrence.

Who Should Conduct Accident Investigations?

The responsibility of investigating accidents concerns all levels of management and the mine safety committee.

The investigation of an accident affords both the supervisors and the mine safety committee an opportunity to learn much about accidents and what causes them, including unsafe conditions and causes of such conditions, unsafe practices, and personal-factor causes of these practices. These conditions, practices, and causes can be determined and corrections introduced before other accidents develop.

As a result of an investigation, corrective measures are taken to prevent a recurrence, and, quite naturally, it falls the responsibility of the front-line supervisors with the assistance of the mine safety committee to see that such actions are introduced to the crew members and then followed.

Accident Facts

A major problem confronting an investigating committee in talking with an injured employee concerning facts of an accident is getting the man to cooperate by telling exactly what happened and how it happened. The accuracy of the accident report will depend, to a great measure, on the individual's willingness to give the facts as he knows them. There are many reasons why a man may be hesitant to give a true and factual account of the episode, some of which are listed below:

1. Fear of ridicule or of creating a bad impression.

The investigators of an accident should conduct themselves in such a manner that the man will be willing to cooperate by telling what he knows and to allay any fears the man might have; otherwise, only untruths and halftruths will be forthcoming. Attempting to give a man a "hard time" will only cause the injured to distort the facts, and nothing constructive will result from the investigation.

Every individual may have his own particular techniques of getting the facts of an accident, but a general pattern is as follows:

1. Remind the employee of the purpose of the investigation.

2. Ask the man for his version of what happened and how it happened.

3.

4.

Ask specific questions of the man.

Check your understanding of the facts as given by the man. 5. Discuss means to prevent recurrence.

In discussing an accident with an injured employee, emphasize at the outset that the purpose of the investigation is to prevent injuries of a similar nature in the future, regardless of who is performing the job. Assure the man that all the facts must be known and fully understood if you are to discharge your duties as his safety representative in helping to prevent accidents. The man must have your confidence and should be reassured that your purpose is constructive only and not to blame someone for the accident.

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If possible, the man should be interviewed at the scene of the accident, which will make an explanation much easier for him. Many men have difficulty in expressing themselves unless they can point to a location, demonstrate a procedure, or relate, in some manner, things difficult to explain.

One important point to remember while the man is giving his explanation is the following: Do not interrupt unless it is absolutely necessary. Wait until he has finished if you have a question. An interruption could break his train of thought.

If some points of the man's description are confusing, ask him specific questions concerning these items. Your questions should deal with what he was doing, how he was doing it, and what happened. Questions as to why the man did what he did should be reserved until the complete story of what happened has been established.

During periods of uneasiness, men will often mean one thing and say something quite different. For this reason, the investigators should verify their understanding of the accident by describing the accident to the injured in his own words. Any conflicting points should be corrected by the man. One point to keep in mind is that it is the investigator's version of the injured's story that is being checked. The interview should be completed by discussing ways to prevent accidents of a similar nature in the future. The injured should be encouraged to express ideas on how the job might be made safer.

Another word of caution: Do not attempt to write the accident report while you are conducting the interview. The accident report should only be written after you have obtained all possible information from all sources.

Following is a brief review of major points to consider when gathering information concerning an injury:

1. Be concerned about the man's injury.

2. Emphasize to the man why the investigation is necessary.

When conducting an accident investigation, the types of witnesses you will be concerned with are the direct, or eyewitness, and the indirect witnesses. The first classification is so called because the man saw the accident occur, and the second classification concerns all individuals who have knowledge of circumstances concerning the accident. Witnesses, both direct and indirect, are prime sources of information and often provide points concerning an accident that will enable the investigators to more fully understand the complete series of events prior to the event which culminated in the final act, the accident. Witnesses present special problems to investigators since some may be hesitant to discuss the accident if they think their information might, in some manner, discredit a fellow worker, while others will withhold information. Some witnesses, with the mistaken idea that they are protecting a friend, will deliberately distort the facts of the accident. The investigator must be aware of these forms of hostility in witnesses and do nothing to further this antagonism. Witnesses need to be reassured, encouraged, and handled with considerable tact, and should be interviewed in a manner similar to that of the person who had the accident, keeping in mind the following:

1.

Interview witnesses separately, not in groups, and as soon as possible after the accident.

2.

Clearly state the purpose of the interview.

3. Develop a complete story of the accident by asking specific questions after the witness gives his version of the story.

4. Summarize your understanding of the accident by checking with the witness.

Accident Report

The report covering an accident, whether fatal or nonfatal, should, of course, be complete in detail, but concise and written in such a manner that even an individual foreign to the industry would fully comprehend a true picture of the circumstances surrounding the accident.

Many organizations have special forms for listing the particulars of an accident, most of which have about the same format. These forms follow a definite sequence for listing accident information and usually can be completed by a minimum of writing by the investigator. In addition to personal information concerning the injured individual and data concerning the specific injury, the following information is necessary in an accident report:

1. Exact location of accident. The exact location is usually best given in terms of distance and direction from some definite landmark, as for example, "Face No. 1 entry, 14 right 9 left section, No. 4-C mine."

2. What job was the man doing? This concerns the job to which the man was assigned and what he was doing or trying to do. Included also should be a description of actions of others, if any, that caused or contributed to the accident.

3. Was the man performing his regular job? Quite often, circumstances require that a man be assigned a job different than his regular duties, which presents different hazards and skills.

4. What basic job step was the injured performing? This portion of the report deals with the part of the job that the man was actually doing when the accident occurred. If, for example, a timberman was striking a safety post with an ax preparatory to moving it to a new location, the job step would be "striking safety post with ax.

5. Was the job step a part of the employee's regularly assigned duties? In an effort to be helpful, an employee may "lend a helping hand" to a fellow employee, and in the process of attempting to be helpful, will become injured, usually because of not being thoroughly familiar with the duties.

6. Description of accident. The description of the accident includes the series of events leading up to and including the accident. In many instances, there are unusual circumstances preceding an accident, in which case a background explanation is necessary to give full meaning to the report. Often this background will be a description of the activities, problems, or conditions that took place or existed before the actual accident sequence. For example, if a timberman suffered a fractured left ankle by a "rib roll", description of the cutting and drilling procedures would be in order if these operations caused a brow to be left in place, and— evidences of other such practices were prevalent on the section. Answers to the following questions will aid in describing the accident: