How to Conduct An Accident Investigation – Simple and Practical Steps to Follow
When an accident happens in the workplace, confusion often follows. People want answers, How did it happen? Could it have been prevented? What must be done now?
Conducting an accident investigation promptly and efficiently can seem overwhelming, especially if there is uncertainty on where to start or what steps to follow.
Accidents don’t happen by chance. There are always underlying factors, sometimes deeply hidden, which contribute to the incident. An effective accident investigation helps uncover these factors, allowing you to address root causes and implement corrective actions promptly.
When done right, it transforms unfortunate events into valuable learning opportunities, improving your company’s safety performance and reducing future risks.
This guide will walk you through a practical, step-by-step approach to accident investigations. You’ll discover how to streamline your processes, communicate clearly, and implement quick, actionable solutions.
Before You Begin… Have You Notified DOSH?
Before diving into the accident investigation itself, it’s crucial to remember your immediate legal obligation, notifying the Department of Occupational Safety and Health (DOSH) Malaysia.
According to Section 32 of the Occupational Safety and Health Act 1994 (Act 514) and the Notification of Accident, Dangerous Occurrence, Occupational Poisoning and Occupational Disease (NADOPOD) Regulations 2004, employers must report certain incidents to DOSH as soon as possible.
If the accident involves a fatality, serious bodily injury, or a dangerous occurrence, you must inform DOSH immediately using the fastest means available such as telephone, fax, or email. Subsequently, a detailed written notification (using Form JKKP 6 for accidents and dangerous occurrences, or Form JKKP 7 for occupational poisoning or diseases) must be sent to the nearest DOSH office within seven days after the incident.
Before starting any accident investigation, make sure you’ve informed DOSH immediately and submitted the required reports within the specified timelines. Staying compliant sets the right foundation for an effective and credible investigation!
Additionally, companies must maintain accurate records of all reportable incidents using Form JKKP 8. This record must be updated regularly, and an annual summary must be submitted to DOSH by 31st January each year.
Prompt and accurate notification is not just a legal requirement. It sets a positive stage for your accident investigation by demonstrating transparency, compliance, and a commitment to workplace safety.
Now that you’ve fulfilled your notification obligations, let’s proceed to conducting your accident investigation effectively and efficiently.
Why Root Cause Matters During Accident Investigation?
When conducting an accident investigation, it’s easy to simply identify what went wrong on the surface. For example, we may quickly see that a worker slipped, a machine broke down, or someone failed to follow procedures.
But effective accident investigations require digging deeper to uncover the underlying issues, the real “why” behind the incident. This deeper process is called Root Cause Analysis (RCA), and it’s essential for preventing future accidents rather than just reacting to them.
Root causes are typically hidden beneath the surface-level symptoms of an accident. They can include systemic problems, such as inadequate training, poor equipment maintenance, unclear procedures, or cultural issues like insufficient safety awareness or pressures that compromise safety. By identifying these deeper issues, RCA enables you to make meaningful changes that prevent similar incidents from happening again.
Don’t just fix symptoms; always identify and resolve the root cause to ensure lasting improvements to your safety performance!
One practical method commonly used for RCA is the “Five Whys” technique. It’s simple yet effective: starting from the immediate cause of an accident, you keep asking “Why?” repeatedly, usually about five times until you reach a fundamental, actionable cause. For example:
- Why did the employee slip? Because there was oil on the floor.
- Why was there oil on the floor? Because the machine leaked.
- Why did the machine leak? Because maintenance wasn’t performed regularly.
- Why wasn’t maintenance performed? Because it wasn’t scheduled clearly.
- Why wasn’t it scheduled clearly? Because the company’s preventive maintenance procedure was incomplete.
In this example, fixing only the immediate symptom such as cleaning the oil spill wouldn’t prevent future accidents. However, improving the maintenance scheduling procedure solves the root cause, significantly reducing the risk of future incidents.
By applying Root Cause Analysis, you turn each unfortunate incident into a learning opportunity that enhances your workplace safety and prevents repeat accidents, creating a safer environment for everyone.
Step 1: Prepare in Advance – Investigation Plan, Toolkit, and Training
Accidents happen unexpectedly, and the immediate aftermath can be chaotic and stressful. To handle these situations effectively, it’s critical to prepare an accident investigation plan and toolkit in advance. Being ready ensures that you can respond swiftly, systematically, and confidently when an incident occurs.
An effective accident investigation plan clearly outlines the procedures to follow immediately after an incident. This plan should define roles and responsibilities detailing who does what and when. Include clear instructions for scene preservation, notification protocols, and steps for gathering evidence and information.
| Accident Investigation Form | |
|---|---|
| Date of Accident | |
| Time of Accident | |
| Location of Accident | |
| Injured Person(s) Name | |
| Job Title | |
| Type of Injury | |
| Description of Accident | |
| Immediate Causes (Unsafe Acts/Conditions) | |
| Root Causes | |
| Corrective Actions Taken | |
| Investigator Name | |
| Date of Investigation | |
Alongside this plan, you should also maintain a ready-to-use investigation toolkit. A typical toolkit should contain essential items such as accident investigation forms, cameras or smartphones for documentation, measuring tape, barrier tape or cones for scene preservation, flashlights with extra batteries, notepads and pens for witness statements, and personal protective equipment (PPE) for investigators’ safety.
In addition to preparing your plan and toolkit, it’s crucial to ensure that all team members receive regular training on accident investigation. Conducting periodic training sessions enhances the preparedness of your investigation team by familiarising them with investigation procedures, maintaining their investigative skills, and keeping everyone updated on any procedural or regulatory changes. Regular training also reinforces the importance of accident investigations and promotes a strong safety culture within your organisation.
By having a robust plan, well-stocked toolkit, and regularly trained team, your organisation will be well-equipped to conduct efficient and effective accident investigations, reassuring your workforce that safety remains a top priority.
Step 2: Secure and Document the Scene Quickly
The immediate aftermath of a workplace accident can be chaotic. Acting quickly and decisively to secure and document the accident scene is crucial for conducting an accurate investigation. A well-secured scene preserves important evidence, helping the investigation team identify exactly what went wrong and why.
The first step in securing the scene is to prevent further harm. Ensure that the area is immediately cordoned off with barrier tapes, cones, or other clearly visible markers. Limit access strictly to authorised personnel, such as investigation team members and emergency responders, to avoid contamination or alteration of vital evidence.
After securing the area, begin documenting the scene thoroughly. Capture clear photographs or videos from multiple angles, including close-ups of any hazards, damaged equipment, or visible injuries. Use measuring tapes to record precise distances and dimensions, as this data might be critical later. Quickly and accurately recording evidence at this stage provides an objective snapshot of conditions immediately following the incident.
As you document, note any environmental conditions such as lighting, weather, temperature, or floor conditions that could have contributed to the accident. It’s also beneficial to record initial witness statements or observations right away, as memories can quickly fade or become influenced by others.
Securing and documenting the scene quickly not only helps establish a reliable foundation for your investigation but also demonstrates your company’s commitment to transparency and safety. The clarity and detail captured at this initial stage will greatly enhance your ability to conduct an effective investigation and implement meaningful corrective actions.
Step 3: Assemble the Right Accident Investigation Team
An accident investigation is only as effective as the team conducting it. Selecting the right individuals to investigate an accident ensures accurate findings and meaningful corrective actions. Therefore, it’s essential to form a competent, balanced investigation team comprising members with diverse skills and perspectives.
Ideally, an investigation team should include a mix of roles, such as a supervisor familiar with workplace processes, a trained safety professional who understands investigation techniques, and technical experts who can assess machinery or specific operational areas involved in the incident. Additionally, involving an employee representative from the Safety and Health Committee or a trusted front-line worker can provide valuable insights and build trust within the workforce.
Each member of the investigation team should clearly understand their specific responsibilities. These responsibilities include securing and documenting the accident scene, conducting witness interviews, gathering relevant records, analyzing collected data, and identifying root causes. Assigning roles beforehand ensures a structured, effective, and timely investigation.
Include a diverse group in your investigation team such as the Safety and Health Committee, supervisors, safety professionals, technical experts, and employee representatives, to ensure thorough and balanced investigations!
It’s also beneficial to ensure that team members receive regular training on investigation techniques, safety regulations, and company procedures. This consistent training equips them with updated knowledge, enhances their analytical abilities, and ensures readiness for immediate response when incidents occur.
By carefully assembling and training a competent accident investigation team, your company will achieve thorough, reliable investigations. Ultimately, a strong team approach promotes continuous improvement, prevents recurrence of incidents, and strengthens your overall safety culture.
Step 4: Gather Complete Information – Witnesses and Records
Once the scene has been secured and documented, it is crucial to gather comprehensive information to build a clear picture of what truly happened. Begin by interviewing witnesses as soon as possible while their memories are still fresh. Interview them individually to avoid group influence on their statements. Use open-ended questions, such as:
- “Can you describe what you saw?”
- “What were you doing when the accident occurred?”
- “Did you notice anything unusual before the incident?”
Record their responses accurately, either by taking detailed notes or, with their consent, recording the conversation. Ensure you remain neutral and avoid blaming language to encourage honest sharing.
Besides witness interviews, gather all relevant records and documentation. This includes:
- Training records of the injured person(s)
- Equipment maintenance logs
- Safety inspection checklists
- Standard operating procedures for the task involved
Combining witness statements with documented data helps confirm facts, identify inconsistencies, and highlight potential gaps in safety systems or training programmes.
Step 5: Analyze Facts to Identify All Contributing Factors
Analyzing the collected facts is the heart of an effective accident investigation. This step goes beyond simply identifying what happened. It seeks to understand why it happened and how it can be prevented in the future.
Start by organising all data systematically. Arrange witness statements, photos, inspection findings, and records in chronological order to recreate a clear timeline of events leading up to, during, and immediately after the incident. Visual timelines or sequence diagrams can help your team see the flow of actions and identify points where normal operations deviated.
Next, differentiate between:
A. Direct Causes
These are the immediate unsafe acts or unsafe conditions that triggered the accident. For example, an employee slipped because there was oil on the floor, or a worker was struck because a machine guard was removed.
B. Contributing Factors
These are circumstances or conditions that allowed the direct cause to occur or made it worse. For instance, the oil spill remained because cleaning was delayed, or the machine guard was removed because production deadlines encouraged shortcuts.
C. Root Causes
These are the underlying system failures or management gaps that allowed contributing factors to exist. In the oil spill example, root causes might include inadequate housekeeping procedures, insufficient supervision, or lack of employee training on immediate spill response. For a removed machine guard, root causes may involve production pressures overriding safety protocols or the absence of periodic safety audits to detect such unsafe practices.
The ultimate goal is not to assign blame but to identify systemic issues that, if corrected, will improve safety for everyone. By understanding how different layers of failure interact, your corrective actions will address weaknesses in the overall safety management system, rather than simply rectifying the immediate cause.
Remember, a thorough and critical analysis at this stage is what transforms your investigation from reactive problem-solving into proactive safety improvement, protecting your employees and strengthening your company’s safety culture.
Step 6: Report Writing and Communicating Findings
The final step in an accident investigation is to compile a clear and concise report. It is important to remember that this report is a legally binding document and must be written professionally, with accuracy, clarity, and objectivity. A well-prepared report not only fulfils legal requirements but also serves as a formal record of the incident, guides management decisions, and becomes a useful reference for future safety improvements.
The report should include basic information such as the date and time of the accident, location, names and job titles of the injured person(s), and names of investigators. It should provide a factual, chronological description of what happened based on observations and witness statements, avoiding blame-focused or emotional language. Supporting evidence like photographs, sketches, maintenance records, training records, and inspection checklists should be attached to strengthen the findings.
Taking into account our previous example of oil spill case, we can produce a simple accident investigation report as following:
| Sample Accident Investigation Report Structure | ||
|---|---|---|
| Section/Title | Description | Example |
| Executive Summary | Brief overview of the incident, investigation, and key recommendations | An oil spill accident occurred on 25 July 2025 causing a slip hazard; investigation identified lack of maintenance schedule as root cause; corrective action proposed to update maintenance procedures and train staff. |
| Introduction | Background details including where, when, and what happened | On 25 July 2025 at 10:45 AM, a hydraulic oil spill was reported at Fabrication Workshop Bay 2, creating a slip hazard for workers. |
| Objectives | Purpose of the investigation | To determine the root causes of the oil spill incident and recommend corrective actions to prevent recurrence. |
| Investigation Members | Names and designations of team members involved | Rahman Iskandar (Safety Officer), Ahmad Faizal (Maintenance Supervisor), Siti Nur (HR Representative) |
| Methodology | Approach used for the investigation | Site inspection, witness interviews, review of maintenance records, and root cause analysis using Five Whys technique. |
| Investigation Findings | Facts gathered, immediate and root causes identified | The hydraulic hose leaked due to wear; no scheduled preventive maintenance for hydraulic lines; worker slipped on the uncleaned oil spill. |
| Discussion | Analysis and interpretation of findings | The lack of preventive maintenance planning contributed to equipment failure. Inadequate housekeeping response allowed the spill to remain, creating a slip hazard. |
| Recommendations | Corrective and preventive actions proposed | Update preventive maintenance schedule to include hydraulic hoses; conduct refresher training on immediate spill response; assign inspection responsibilities clearly. |
Finally, the report must summarise the direct causes, contributing factors, and root causes identified, explaining how each factor led to the incident. It should clearly state recommended corrective and preventive actions, assign responsible persons, and include proposed completion dates to ensure accountability.
The report should also mention how these actions will be followed up and monitored to demonstrate management’s commitment to preventing similar incidents in the future.
Conclusion
Accidents can happen anywhere, but what truly defines a safe and responsible organisation is how it responds to them. Conducting a practical and fast accident investigation is not just about fulfilling legal requirements; it is about protecting your people, learning from every incident, and continuously improving your workplace safety culture.
By following each step systematically from preparation, root cause analysis, reporting, to sharing lessons learned, you are building a proactive environment where safety is prioritised, and everyone goes home safely at the end of the day.
Take the time to review your current accident investigation process, equip your team with the right knowledge and tools, and encourage open reporting without fear of blame. Start today by ensuring your investigation plan is ready and your team understands their roles clearly. Every accident investigated thoroughly and professionally is a step towards preventing the next one. Together, we can create a safer and healthier workplace for all.
Read
Occupational Safety and Health Administration. (n.d.). Incident Investigation. Retrieved from https://www.osha.gov/incident-investigation
Canadian Centre for Occupational Health and Safety. (n.d.). Accident Investigation. Retrieved from https://www.ccohs.ca/oshanswers/hsprograms/investig.html