Accident Investigations: Getting It Right to Prevent the Next One

By Nicola Coote

Often, we don’t realise how quickly our working environment can change. In just a matter of seconds, an accident can occur, and it is a shock to everyone. It’s in these brief moments that we find ourselves questioning how such an incident could have happened.

Organisations often promise to get to the root of the problem that caused it but then complete an investigation that barely scrapes the surface. When this occurs it’s a lost opportunity and the potential for recurrence exists.

Accident investigations can be seen as time-consuming, technical or invasive. So how can we get the best out of the limited time and resources available to ensure our accident investigation process provides value? Here are some hints and tips to guide you.

What is the Purpose of an Accident Investigation

In short, the main goal must always be to prevent recurrence.

When we hear the term “accident investigation,” it often stirs up a sense of dread; we don’t have the time, there are other pressing priorities and people get defensive. Whilst an accident investigation can take time to complete, they are necessary to help us uncover the root cause. By investing this time, we can prevent similar incidents from happening in the future.

There are likely to be some uncomfortable conversations when you start to ask questions about what happened. It’s important to remember that the goal is NOT to point fingers or assign blame. Instead, it’s about finding the problem. Accidents are unpredictable events that reveal weaknesses in your systems. The trick is to develop a culture that enables transparency and openness, and this is a key feature of a good health and safety culture. An open investigation culture promotes positive behaviours.

Rather than fearing an investigation, we should see it as a valuable tool for improvement and safety.

What Accidents Should We Investigate?

Understanding the types of accidents/ incidents to investigate is one of the first crucial steps. Document your investigation process and include guidance on what to investigate, how to investigate and the level of detail needed for different events. Each organisation has its definition of accident, incident etc. Focus on the actual or potential consequence and don’t get bogged down in terminology.

Here are the two main categories we focus on:

Near Miss:

These are unintentional events with high potential but did not result in damage, injury, or harm. They happen without prior planning and can vary in severity. Serious near-miss events, i.e. those where the consequences would have been significant, are sometimes investigated but are often ignored. It’s often seen as a lucky escape, so your accident investigation process should detail when near-miss incidents must be investigated.

Accident: An accident is unexpected and unplanned. It typically results in damage to property or equipment or a person, or even a fatality. The more serious the accident is (or potential), the deeper your investigation should be.

Top Tips when Staring an Accident Investigation

We have highlighted some common errors we experience when reviewing accident investigation processes. These tips will help you to get the best out of your process.

What is the difference between a Witness or Bystander?

Why is this relevant? When an accident occurs, everyone is in shock, and they respond in different ways.

People in the area often state that they saw what happened and it isn’t until you start to interview them that it becomes clear that they didn’t see what happened. Rather, they heard the noise and turned around – ie they saw the result of the accident, and not what caused it. These people are referred to as bystanders. They are valuable when collating information for your accident investigation but they are not witnesses. Therefore, you need to establish who saw the whole thing (i.e. a witness) and who turned around when they heard the commotion as the accident happened (i.e. bystander).

Interview your witnesses and bystanders as soon as possible.

This should ideally be within the first 24 hours, even if the initial conversation is an informal chat to establish who saw what (see above). According to research, as far back as Hermann Ebbinghaus in 1880, it is known that we forget or distort up to 80% of what we see, hear and learn within a very short period, sometimes as little as 24 hours. Ebbinghaus called his research The forgetting curve. Other studies have been completed since, and the results are similar. Therefore time is critical and the longer an investigation is left, the more likely it is that key information will be partly or fully lost or distorted.

Who should investigate?

Often, the wrong person is allocated to complete the investigation. Sometimes this is because the organisation has a blanket policy that specifies a particular role holder, e.g. line manager, as the person responsible. This role holder is often not provided with any training in accident investigation and report writing and does not have the expertise, competence or time.

Organisations that have their own health and safety specialists often allocate this person as their investigator This is a good starting point, but that person is likely to need additional expertise, e.g. in production, the process or the machinery. Therefore, an accident investigation process should have a key person to lead and include other specialists where relevant, such as engineers, supervisors and even external technical specialists.

Follow specialist guidance

The Health and Safety Executive has written practical and user-friendly guidance on how to complete a suitable and sufficient accident investigation. This document is HSG245. It provides comprehensive guidance and can be downloaded free of charge from the HSE website. Our own IOSH Approved training course “Accident Investigation and Report Writing” is based on the principles in this guidance.