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published on

December 2023

Steps in the Accident Investigation Process: Key Overview

Although proper process safety and risk management can significantly reduce their likelihood, on-site incidents still happen. When an incident occurs, it’s crucial to know the most important steps in the accident investigation process, which include:

  • Promptly responding to the incident
  • Planning an investigation
  • Gathering data and accounts from eyewitnesses
  • Releasing the incident scene for further work
  • Analyzing collected data
  • Creating an accident report and sharing your findings
  • Determining corrective steps
  • Making changes

Following these steps will help you identify the chief causes of the incident in question, as well as reduce the likelihood of it occurring in the future. Let’s take a closer look.

The Importance of Thorough Incident Investigation

Responding to and investigating any on-site the right way is just as important as investigating it in the first place. A thorough, methodologically sound incident investigation:

  • Ensures that all possible data regarding the incident is collected and analyzed
  • Prevents key data or evidence from being contaminated or destroyed
  • Allows you to gather eyewitness accounts while they are fresh (and less likely to be degraded by time or corroboration)
  • Empowers your team to make changes in policy, people, or procedure to minimize future risks
  • Eases the concerns of agencies such as OSHA, CSB, and the EPA, which will be involved to some extent
  • Prepares your organization for possible litigation

In addition, if you already have an incident investigation playbook ready to go, your team will spend more time figuring out what happened and how to stop it from happening in the future than deciding how to proceed. Time is of the essence in the aftermath of a dangerous or destructive incident. A solid process helps you make the most of it.

More importantly, if an incident is caused by a preventable factor or element, launching an investigation could allow you to determine its root cause. You may then neutralize that dangerous cause sooner rather than later.

A team in the data gathering stage of an incident investigation wearing hard hats and inspecting equipment.

 

Key Steps in the Process of Accident Investigation

Now that you see why it’s critical to investigate incidents properly, let’s examine the critical steps of the accident investigation process one by one.

Respond to the Incident

An incident in progress is one you can’t investigate. To that end, take whatever steps are necessary to respond to or resolve an incident quickly and safely. Responding rapidly doesn’t just allow you to preserve vital evidence for your upcoming investigation. It also significantly mitigates danger to on-site personnel.

Responding to a facility or worksite incident may include steps like:

  • Notifying emergency responders
  • Noting changes to the facility by emergency response
  • Securing the site with emergency equipment or personnel
  • Transporting injured personnel to medical facilities or bringing emergency responders to them
  • Shutting down work if necessary
  • Blocking further access to equipment or materials that could be dangerous

Person in fire protection gear responding to a facility incident with a firefighting foam.


Plan an Investigation

Your incident response team shouldn’t immediately jump into the investigation. Even if you have a generalized step-by-step process outlined, plan this specific investigation for a few important reasons. For example, hasty investigations are more likely to contain mistakes. But properly planned investigations ensure that the examination of the site goes smoothly and that no vital data points are missed.

Planning your investigation doesn’t need to take a long time if your team members have been appropriately trained. During the planning process, your team members may:

  • Determine the resources that are needed and what procedures will be enacted
  • Identify who will be involved, such as who will head the investigation and manage team members
  • Estimate how long the investigation will take
  • Contact any necessary third-party agencies, such as OSHA

Additionally, your response team should consider requesting a third party investigation from professionals like BakerRisk. A fresh set of knowledgeable eyes can provide big benefits to your investigation, as we explore in this webinar.

Gather Data & Accounts

Now it’s time for your incident response and investigation team members to gather as much data as they can. Physical or scientific data, such as measurements and readings, documents, computer logs, and other files, are critical. Changes to the site as part of the incident response should be recorded. Investigation team members should take photographs and video footage wherever possible (and create backup copies of important files/documents).

But they should also gather eyewitness accounts while they are “fresh,” before time starts to shift individual recollections. Always be sure to accurately document any witness accounts, even if a witness didn’t directly see what happened. Accounts of on-site personnel who heard or otherwise sensed something at the time of the incident could be very important later on.

All evidence collected should be logged and stored in a secure facility. Note that you must restrict access to this evidence so that only qualified team members or third-party agency specialists can access the material. The same must be true of evidence alterations – only allow authorized individuals or agencies to change evidence under protocols approved by all interested parties.

If your team needs to brush up on incident investigation techniques, tools, and strategies, BakerRisk’s training programs are excellent resources.

Release the Incident Scene

Many incidents will not be so damaging to equipment or infrastructure that they prevent work from continuing. When appropriate, release the scene of the incident after data collection and measurements have concluded. That way, operations can partially or fully resume.

Site remediation and clearance for work may include calling in specialists to remove harmful chemicals or toxins, replacing damaged equipment, and more. Don’t forget to speak with representatives of third-party agencies like OSHA to make sure it is legal and safe to resume work at an incident site before recalling workers.

A man in PPE checking equipment following an accident investigation before releasing the scene.

 

Analyze Collected Data

At this stage in the incident investigation process, it’s time to analyze the data your team has collected and test various hypotheses as to the incident’s root cause(s).

It is generally wise to organize data chronologically. This will allow your team to reconstruct the incident, as well as identify any contributing factors or causes that led to damages. State-of-the-art tools like BakerRisk’s CATree can help you perform root cause analyses.

It’s also a good idea to organize data locally (e.g., using a graph, model of the building, etc.) to show which data/causes affected which areas of an incident site. In this way, analysts will be able to visually determine how different aspects or elements of the incident are related to each other.

In any case, the overall goal of this phase is to determine why something happened and, just as importantly, how it may be prevented going forward. No site failure or mistake happens by itself. In many cases, multiple smaller issues or errors compound upon each other enough times to eventually cause a catastrophe.

Create an Accident Report & Share Findings

The only way to make sure an incident doesn’t occur again for the same reasons is to put relevant data, insights, and conclusions into a comprehensive report, complete with detailed graphs, explanations, and recommendations. Your investigation team should ensure that the report is easy to distribute, completely accurate, and understandable to those who may not necessarily be familiar with the incident’s details.

An accident report should include:

  • A detailed summary of what happened
  • Conclusions about why the incident occurred, including analyses of different factors and their contributions to the incident
  • Documentation such as photos, graphs, records of witness statements, etc.
  • Hypotheses that were proven false

After the report is created, share it with necessary individuals and organizations. Your organization should, of course, store copies of this report as well – it may be used in future litigation when defending your organization or determining who is at-fault (if applicable) for the incident and related damages.

Determine Corrective Steps

Toward the end of the incident investigation process, your team and organization executives or managers will decide on which corrective steps are needed. In theory, corrective steps will be based on the recommendations provided in the above-mentioned report. However, if the right corrective steps require additional engineering skills or expertise outside of the investigation team’s abilities, the investigation team may need to call in others or third parties to help them implement changes.

All corrective steps should:

  • Address the root causes of the problem, not secondary concerns or unrelated policy gaps
  • Be specific in that they should directly solve for or fix the root causes and problems at the heart of the investigated incident
  • Be actionable in that they should be achievable or able to be implemented in a reasonable timeframe

Make Changes in Policy, Procedure, or Production

Once corrective steps have been outlined and decided upon, it’s time to implement them across your organization and affected worksites. Your organization as a whole can take whatever steps are necessary to implement the recommended changes, such as altering worksite procedures, making additions or corrections to company policy, and increasing training.

However, note that all proper policy, personnel, or procedure changes should include follow-ups and checkups from management or incident specialists. This will ensure that the mistakes that originally caused the investigated incident are not repeated and that personnel know the new procedures they should follow going forward.

Conclusion

Ultimately, having a detailed playbook of incident investigation steps ready to go will help your organization respond to any accident with agility. BakerRisk helps facilities with many of the steps of the incident investigation process, including hazard analysis, the development of new safety procedures, and more. We also assist when collecting, logging, storing, and maintaining evidence. Get in touch with one of our specialists today to learn more.