BOS 4601, Accident Investigation 1 Course Learning Outcomes for Unit VIII Upon completion of this unit, students should be able to: 2. Describe the accident investigation process. 2.1 Identify the key elements of an accident investigation report. 6. Examine the relationship between accident investigation and hazard prevention. Reading Assignment Chapter 14: Reporting and Follow-up Chapter 15: Learning from Accidents In order to access the resource below, you must first log into the myCSU Student Portal and access the Business Source Complete database within the CSU Online Library. Geller, E. S. (2014). Are you a safety bully? Professional Safety, 59(1), 39-44. Access the resource below, and read Reporting the Results (pp. 2-92 to 2.110): U.S. Department of Energy. (2012). Accident and operational safety analysis: Volume I: Accident analysis techniques. Retrieved from http://energy.gov/sites/prod/files/2013/09/f2/DOE-HDBK-1208- 2012_VOL1_update_1.pdf Unit Lesson Accident investigations can take days, weeks, or months to complete, depending on the complexity of the accident and the organization’s approach to the accident investigation process. That means a comprehensive investigation takes resources to complete—resources that could be used for more productive pursuits. However, if organizations are diligent and implement the corrective actions identified through accident investigation, they will gain in the long run by not having to investigate the same accidents repeatedly. Corrective actions eliminate hazards, and eliminating hazards reduces the probability of accidents. However, cost avoidance is not always easy to sell. Safety practitioners need to keep the cost of accidents visible. Production delays, cleanup, investigation, and training are all significant hidden costs related to accidents, and they should all be tracked. We have said that accident investigation is a reactive process. When we implement corrective actions, the process becomes proactive. Information about accidents and corrective actions should be communicated to all levels of an organization. Organizational managers need to see the cost of accidents, and employees need to see that actions to protect them from injury have been taken. Communicating accident information begins with the accident investigation report. What this report will look like may depend on the organization’s philosophy concerning accidents, the seriousness of the accident, or the resources available. The Occupational Safety & Health Administration (OSHA) requires most organizations to keep a log of injuries and illnesses (OSHA, 2001). The OSHA 300 log is a basic description of the who, what, and where of injuries and illnesses. Some organizations expand the OSHA log to include causal factors and corrective actions. Accident forms are reports that contain more room for detail about an accident, but they still follow a “fill-in-the-bla ...

1. BOS 4601, Accident Investigation 1
Course Learning Outcomes for Unit VIII
Upon completion of this unit, students should be able to:
2. Describe the accident investigation process.
2.1 Identify the key elements of an accident investigation
report.
6. Examine the relationship between accident investigation and
hazard prevention.
Reading Assignment
Chapter 14:
Reporting and Follow-up
Chapter 15:
Learning from Accidents
In order to access the resource below, you must first log into
the myCSU Student Portal and access the
Business Source Complete database within the CSU Online
Library.
Geller, E. S. (2014). Are you a safety bully? Professional

2. Safety, 59(1), 39-44.
Access the resource below, and read Reporting the Results (pp.
2-92 to 2.110):
U.S. Department of Energy. (2012). Accident and operational
safety analysis: Volume I: Accident analysis
techniques. Retrieved from
http://energy.gov/sites/prod/files/2013/09/f2/DOE-HDBK-1208-
2012_VOL1_update_1.pdf
Unit Lesson
Accident investigations can take days, weeks, or months to
complete, depending on the complexity of the
accident and the organization’s approach to the accident
investigation process. That means a comprehensive
investigation takes resources to complete—resources that could
be used for more productive pursuits.
However, if organizations are diligent and implement the
corrective actions identified through accident
investigation, they will gain in the long run by not having to
investigate the same accidents repeatedly.
Corrective actions eliminate hazards, and eliminating hazards
reduces the probability of accidents. However,
cost avoidance is not always easy to sell. Safety practitioners
need to keep the cost of accidents visible.
Production delays, cleanup, investigation, and training are all
significant hidden costs related to accidents,
and they should all be tracked.
We have said that accident investigation is a reactive process.
When we implement corrective actions, the
process becomes proactive. Information about accidents and

3. corrective actions should be communicated to
all levels of an organization. Organizational managers need to
see the cost of accidents, and employees need
to see that actions to protect them from injury have been taken.
Communicating accident information begins with the accident
investigation report. What this report will look
like may depend on the organization’s philosophy concerning
accidents, the seriousness of the accident, or
the resources available. The Occupational Safety & Health
Administration (OSHA) requires most
organizations to keep a log of injuries and illnesses (OSHA,
2001). The OSHA 300 log is a basic description
of the who, what, and where of injuries and illnesses. Some
organizations expand the OSHA log to include
causal factors and corrective actions. Accident forms are reports
that contain more room for detail about an
accident, but they still follow a “fill-in-the-blank” format. Logs
and forms have their place and are useful for
UNIT VIII STUDY GUIDE
Reporting and Follow-Up
BOS 4601, Accident Investigation 2
UNIT x STUDY GUIDE
Title
establishing trends or tracking corrective actions, but they are

4. not a substitute for the accident investigation
process. A compete accident investigation report should contain
all the facts obtained during the investigation,
copies of interviews and statements, photographs, discussion of
the analytical process used to develop the
causal factors and corrective actions, and discussion of all
causal factors and proposed corrective actions
(Oakley, 2012). In other words, it documents the entire process.
Realistically, most organizations do not have
the resources to conduct an in-depth investigation for every near
miss, minor injury and major injury. They
choose to put more resources into the accidents with more
serious consequences but require reporting using
logs or forms for all accidents, regardless of the severity.
Regardless of the format, accident investigation reports have
little value if actions are not taken to implement
the corrective actions. This is where the process becomes
proactive and justifies the resources expended in
the investigation. Accident causal factors represent hazards or
workplace conditions that may cause illness or
injury. They are no different than hazards identified through
workplace compliance inspections, job hazard
analysis, or risk assessment; therefore, they should become a
part of whatever hazard tracking system is in
use (presuming there is such a system. If not, the problems go
much deeper than accidents). Each corrective
action should be clearly assigned to a specific individual or
group who is then held accountable for completion
of the necessary tasks. Periodic follow-up is necessary to ensure
established timelines are met and that the
corrective actions are working as intended.
Learning from accidents is important. Even if our corrective
actions are implemented and are effective in
preventing a recurrence, is there anything revealed by the

5. investigation that can be applied to other parts of
the organization, even if different processes are involved?
Looking back one last time at our accident scenario
involving Bob slipping in the water on the floor, we identified
that supervisors in the valve department were not
aware of their responsibility to submit maintenance requests.
Does the same problem exist in other
departments? Perhaps the overall preventative maintenance
program is inadequate? Likewise, we identified a
communication problem between supervisors and employees. Is
this an indicator of a systemic problem?
It takes practice to become an effective accident investigator.
Large organizations may have a team
dedicated to accident investigations. There are government
agencies, such as the National Transportation
Safety Board and the U.S. Chemical Safety Board, whose sole
purpose is accident investigation. For most
employers, the opportunities to conduct a thorough
investigation are not frequent enough to provide the
needed practice. On one hand, not having accidents to
investigate is a good thing and may indicate the
presence of an effective safety program (or a string of good
luck). On the other hand, the lack of practice
might result in a poor-quality investigation. If we understand
the theories of accident causation, there is no
reason we cannot apply those theories proactively to reveal
potential accident causes. Accident prevention is
much more than eliminating hazards from the workplace. It
requires an examination of systems and the
interactions among workers, equipment, and processes.
It is not hard to brainstorm the types of accidents that might
happen in a given workplace. Using an imagined
accident or an accident that happened in another organization,
you can work backwards and examine the

6. conditions that might contribute to such an accident. Applying
the various domino theories will help focus on
unsafe actions and unsafe conditions or basic and immediate
causes. We can use the Haddon matrix to help
identify human, equipment, and environment factors. We can
use change analysis to identify what alterations
in a process or procedure might result in an accident, and we
can use barrier analysis to determine if the
barriers in place are sufficient and to decipher what might
happen should they fail. Fault tree analysis can be
used to examine complex processes for potential paths to an
accident (Oakley, 2012).
Accidents happen. They happen in organizations with no active
safety programs, and they happen in
organizations with large staffs of credentialed safety
professionals. They are elusive because they involve
complex interactions of human behavior, equipment, and the
environments in which they operate. No one can
accurately predict when or where an accident will happen, but
we can, and should, learn at least something
from every accident. The accident investigation process is the
conduit for this learning. The more we learn,
the more we can reduce the probability of another accident. We
can also be proactive and apply accident
theories to identify vulnerabilities in processes and procedures.
No one is happy when an accident happens, but each accident
should be viewed as a unique opportunity for
improvement. Not taking advantage of these opportunities does
a great disservice to those workers who were
adversely affected. We owe them, their families, and their
colleagues our best efforts.

7. BOS 4601, Accident Investigation 3
UNIT x STUDY GUIDE
Title
References
Oakley, J. S. (2012). Accident investigation techniques: Basic
theories, analytical methods, and applications
(2nd ed.). Des Plaines, IL: American Society of Safety
Engineers.
Occupational Safety & Health Administration. (2001). 29 CFR
1904.7, general recording criteria. Retrieved
from
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_t
able=STANDARDS&p_id=9638
Suggested Reading
In order to access the resources below, you must first log into
the myCSU Student Portal and access the
Business Source Complete database within the CSU Online
Library. To reduce the amount of results you
receive, it is recommended to search for the article by title and
author.

8. The Royal Society for the Prevention of Accidents (RoSPA)
believes that there are many opportunities for
learning in the field of safety prevention. This article focuses
on RoSPA’s key theme that understanding
accidents is important in preventing them. This article also
contains other interesting information about
RoSPA and its investigation practices.
Bibbings, R. (2010). Learning from accidents. RoSPA
Occupational Safety & Health Journal, 40(7), 35-36.
The article below explores the Chemical Safety and Hazard
Investigation Board and how this organization is
trying to prevent chemical accidents. Their five core goals are
identified and discussed in the article, as well.
Bergeson, L. L. (2006). The Chemical Safety and Hazard
Investigation Board: Thinking strategically in
investigating (and preventing) chemical accidents.
Environmental Quality Management, 16(2), 81-88.