Guidelines on using the guide to learn from accidents

Often there is not just a single reason for an accident, but rather it's a question of interaction between several reasons all of which are equally significant. Knowing the different reasons makes it easier to take preventive steps.

Use the guide to:

  • identify the chain of events occurring prior to the accident
  • identify the interaction between physical problems, personal carelessness and oversights in planning
  • investigate whether similar accidents could occur, including at other places in the enterprise
  • identify where safety could be improved.

This method can also be used to analyse dangerous incidents which could have resulted in personal injury.

How to use the guide

The guide includes six steps which can be adapted to the situation, as well as the personal preferences of the person analysing the accident.

1. The person investigating the accident must ensure that the relevant persons are present, otherwise it may often not be possible to complete the analysis. The relevant persons could be the injured party, witnesses to the accident, management and employee representatives as well as persons with a technical insight into the work process in which the accident has occurred.

2. Start by creating a “joint picture” of what happened. Use the first three questions in the guide as your point of departure. Also use, for example, a reconstruction of the accident, make a drawing or take a look at the accident site/machinery. This is the start of the analysis.

3. Use the tool actively - distribute the guide (Word, 515 KB) or the equivalent dialogue board (PDF, 398  KB) to the participants and get them to consider the reasons for the accident.

  • First, identify the physical factors that caused the accident.
  • Then identify the planning-related or personal factors causing the physical problems.

The guide includes clarifying questions for each cause, which can then be ticked off. Furthermore, it is possible to note comments and other information on the lines under each question.

4. The person investigating the accident may, depending on the situation, participants and method, choose to use the guide as a tool in the dialogue or as a checklist.

The guide as a tool:

  • Give participants good time to answer the questions themselves so that they can contribute to identifying the reasons for the accident. Participants are then able to reflect on the reasons for the accident and maybe even remember more reasons than when they first thought about it.
  • Put the dialogue tool on the table for everyone to see. Review the causes together and put into words what might lie behind every cause. Use the auxiliary questions in the guide to support the dialogue and formulate the reason.

The guide as a checklist:

  • Use the guide to finish the dialogue in order to ensure that you have fully covered all issues in the dialogue about the accident.

5. Get the participants to consider whether the same accidents may happen again at the same place or other places in the enterprise. This could be similar tasks and work sites, or work with similar technical equipment or machinery.

6. Finally, discuss how the analysis shows that safety must or should be improved. Discuss and investigate options. Also consider whether there are areas in the enterprise where you feel safety is good and from where you may be able to transfer the same measures and experiences.