Accident Investigation - Learning from Unwanted Events
The Accident Investigation
Protocol is a guide to learning from accidents, incidents and other types of unwanted
Purpose of Accident Investigation
The importance of learning from unwanted events should made be clear. This can be done through
various ways, written communication, training, toolbox meetings etc.
knows the problems that may lay ahead and has taken measures to (1) prevent their
occurrence and (2) cope with their consequences should they nevertheless take
The main reason for learning from unwanted events is to eliminate and reduce undesired or
unwanted events and their consequences such as:
suffering due to personal injury and occupational illness
damage to product, equipment and the environment
loss of customers
company image damage
with the aim to:
It is important to define what types of unwanted events must be reported, investigated and
analyzed, by whom, when and how and how remedial actions shall be managed to completion. The broader the
scope of the definitions, the more opportunities there are to improve the efforts to eliminate and/or reduce
human suffering and unnecessary cost of production.
Accident Investigation model
It is important to accept a model that relates the unwanted event and its outcome to the
management system. That way a manageable system can be set up and communicated in which all levels in the
organization will be able to play their roles. The model provided via this website is generally accepted and
can be easily applied to various areas of business management: safety, quality, cost control
Classification of Risk - determine with events to investigate
Risk classification is important to
determine the potential risk. The outcome of the process helps to:
- which levels of management should be involved
whether a cause analysis shall be carried out
which methods should be used for investigation and cause
whether a team approach should be used to contribute to investigation and analysis;
possibly including (external) expertise
the management level of the team chairperson
selecting remedial actions and deciding budget provisions
Accident investigation responsibilities
Clear responsibilities should be established for:
reporting of accidents / incidents defined in the protocol
investigation of these accidents / incidents to collect facts
cause analysis to uncover the causes that have led to the
development and follow-up of remedial actions
Responsibilities should preferably be put in writing and communicated.
To make sure that remedial actions will be carried our properly and in time, consider the
- event coordinator - person responsible for everything that is related to the accident, incident or
event, including the actions to be taken
- action owner - person responsible to assure that the action is carried out properly an in time. This
could be the person who actually carries out the action or a person who makes sure that somebody else, possibly
outside the company or organization, carries out the work.
For further details go to "accident and incidents"
and follow the reading sequences indicated at the bottom of the pages.
Accident investigation is a main source for system improvement
Learning from accidents, incidents and other unwanted occurrences is vital to improve the entire sequence
involved in the causation sequence, all the way up to the management system.