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Accidents are unplanned and unintentional events that result in harm or loss to personnel, property, production
or nearly anything that has some inherent value. Accidents are rarely simple and almost never result from a
single cause. Most accidents involve multiple, interrelated causal factors. Accidents can occur whenever
significant deficiencies, oversights, errors, omissions or unanticipated changes are present. Any one of
these conditions can be a precursor for an accident; the only uncertainties are when the accident will occur
and how severe its consequences will be.
Understanding how to prevent or control accidents requires an understanding of the sequence of events leading
to an accident. This is called the fact-finding phase of an accident investigation, and the results will assist
in identifying and implementing countermeasures. When conducting the fact-finding phase of an investigation,
the investigating team should:
- Gather evidence from all available sources.
- Get information from any written reports, as well as by onsite observations.
- Interview witnesses as soon as possible after an accident.
- Inspect the accident site before any changes occur.
- Take photographs and make sketches of the accident scene.
- Record all pertinent data on maps.
- Get copies of all reports, documents containing normal operating procedures, flow diagrams, maintenance charts or reports of difficulties or abnormalities.
- Keep complete and accurate notes in a bound notebook.
- Record pre-accident conditions, the accident sequence and post-accident conditions.
- Document the location of victims, witnesses, machinery, energy sources and hazardous materials.
- Include any particular physical or chemical laws, principles or properties that may explain a sequence of events.
- Gather data that may lend itself to analysis by these laws, principles or properties.
- An appendix in the final report can include an extended discussion of these laws, principles or properties.
COPYRIGHT ©2002, ISO Services Properties, Inc.
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