Accident Investigation Recognize

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Accident InvestigationRecognize Investigate

• SCF Arizona

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Basic Elements of Safe Behavior

Skill
Knowledge
Attitude
Knowledge - Train employees Skill - Provide
employees opportunities to acquire it Attitude -
Motivate employees
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Accident Prevention and Control

• The best way to control costs is to recognize
  hazards and to prevent accidents from occurring.
• If an accident does occur, it must be
  investigated to determine the cause.

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Vocabulary

• Accident
• Hazard
• Near miss
• Unsafe condition/act
• Hazard inspection
• Accident investigation

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Accident

• An accident is an unexpected and unplanned
  event that may result in damage or injury.

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Accidents

• All accidents are caused.
• They are the result of an unsafe behavior, an
  unsafe condition or a combination of both.
• Other causes of accidents may include policies,
  procedures and the corporate culture.

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Hazard

• A hazard is a source of risk or harm.
• (This can be a physical hazard or an unsafe
  behavior.)

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Near Miss

• Near miss describes incidents in which, given
  a slight shift in time or distance, injury or
  damage could have occurred but did not.

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Accident Investigation

• An effective program provides for
  investigations of accidents and near miss
  incidents, so their causes and the means to
  prevent future incidents are identified.

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Accident Theories

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H.W. Heinrichs - Causation Factor Model
Unsafe acts 88 Machine related 10 Acts
of God 2

10 20 40 60 80 100
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The Accident Pyramid
Fatality

Result
Severe Injury
Minor Injury
Behavior
Near Miss
Unsafe Acts
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H.W. Heinrich Accident Causation Theory 300-29-1
Ratio

Severe injury/fatality
Minor injuries
Near misses, incidents resulting in
no injuries
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Common Attitudes

• It was fate.
• He was careless.
• Hes accident prone.
• She did a stupid thing.
• She didnt use common sense.
• What was the last excuse you had?

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Unsafe Condition or Act?

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Unsafe Condition

• Any physical hazard related to equipment,
  materials, structures or other physical elements
  of a workers environment.

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Unsafe Conditions Include

• Poor housekeeping
• Lack of guarding
• Poor maintenance
• Defective equipment
• or tools
• Improper material storage
• Slips, trips and fall hazards

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Unsafe Act

• Any hazard
• created as a
• result of a
• human action
• or behavior.

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Unsafe Acts Attributed To

• Lack of adequate training
• Improper work techniques
• Poor attitude
• Shortcut to save time
• Lack of proper equipment and tools
• Poor leadership

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Other Factors to Consider

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Expected Consequences Drives Behaviors

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Symptoms vs. Causes

• Symptoms Unsafe acts/conditions, which we can
  see, often resulting in accidents.
• Causes Underlying reasons for accidents, which
  we cant see They are identified only by
  investigation.

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Examples of Symptoms

• Careless operation of a forklift truck
• Oil on the floor
• Standing on the top step of a ladder
• Improper lifting techniques
• Not wearing eye protection

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Examples of Causes

• Ineffective employee motivation
• Lack of accountability
• Poor maintenance of facilities
• or equipment
• Inadequate employee training

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Example

• Symptom Climbing an unsafe ladder
• Cause Having a defective ladder
• Solution Replace ladder
• What are other causes to consider?
• An improved inspection program
• Improved training
• Redefinition of responsibilities
• Pre-job planning

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Proactive vs. Reactive

• Most accident investigation techniques
• are reactive.
• After an accident occurs, the cause and
  corrective action is identified.
• Proactive techniques allow you to identify
  potential hazards before an accident occurs.

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Accident Investigation

Used to determine how and why an accident
occurred.
All accidents, whether they result in injury or
not, must be investigated properly.
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Accident Investigation

• All accidents must be investigated
• This should include near misses
• The extent of the accident will determine the
  degree of investigation

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Why are Accidents Investigated?

• Determine direct causes
• Uncover contributing accident causes
• Prevent similar accidents
• Document facts
• Provide information on costs
• Promote safety

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Reason for Investigating Near Misses

• Leads to preventing future accidents that could
  cause serious injuries or property damage.
• Alerts employees to hazards of which they may not
  been aware.

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Fact Finding Vs. Fault Finding

• The goal of the accident investigation is to
  discover the facts - not to place blame.

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Fact Finding vs. Fault Finding

• Fact Finding
• Worker didnt wear proper protective equipment.
• Ladder was not set up properly.
• Worker tripped over uncoiled hoses.

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Fact Finding Vs. Fault Finding

• Fault Finding
• Lazy
• Careless
• Stupid
• Inattentive
• Accident prone

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The Investigation Process

• Equipment
• Materials
• People/Behavior

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Investigation Process

• Define the scope of the investigation
• Select investigators
• Visit accident site
• Interview witnesses and victim(s)

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Investigation Process

• Analyze data
• Determine most likely sequence of events
• Conduct post accident briefing and prepare report

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Define the Scope of the Investigation

• How big was the accident
• Investigating a near miss will not require the
  same resources or details as investigating an
  incident with injuries or a fatalities.
• Can one person investigate or is a team required?

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Select Investigators

• The person investigating the accident should have
  knowledge of the procedures and hazards of the
  operation.
• Additional investigators may include
• Department manager
• Safety committee members
• Managers from other departments
• HR representative

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Visit The Accident Site

• This should be as soon as possible after the
  accident.
• If possible, leave equipment and material in
  their time-of-accident locations.
• Take photographs of the accident site for future
  reference.

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Visit The Accident Site

• Your investigation kit should include
• Paper/pencils
• Investigation report
• Caution tape
• Camera
• Sample containers
• Flashlight/batteries
• Warning signs
• Tape measure
• Cassette recorder

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Visit The Accident SiteObservation
Recognition Techniques

• Understand the work activity objective.
• Be familiar with the standard/accepted method to
  complete the task.
• Look for attitudes, regardless of behavior.
• Trust your first impression.
• Know the facilitys accident history.

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Interview

• Interview witnesses and victim(s) as soon as
  possible.
• Separate witnesses and victim(s) until each is
  interviewed.
• Ask open-ended questions
• Interview all people who were in the area
  immediately before or after the accident.

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Analyze data

• Analyze data to determine abnormal
  activities/behaviors before the accident.
• Determine if any abnormality occurred.
• Determine how the accident occurred and when it
  was first noticed.

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Determine Sequence of Events

• Make a time line of events leading up to the
  accident.
• Consider alternative sequences.
• Compare sequence to data recovered.

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Conduct Post Accident Briefing

• Brief Management as to your findings.
• Prepare a summary report.
• Make sure recommended actions to prevent
  reoccurrence are included in the report.

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Report of Investigation

• The investigation is not complete until the
  report is prepared and submitted.
• The report should include
• Background information
• Accounts of the accident
• Analysis of the accident
• Recommendations

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Corrective Action

• Once the cause of the accident is determined,
  correction action must be implemented to prevent
  reoccurrence.

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Implementing CorrectiveAction Change

• To implement workers changes
• Identify behaviors
• Explain benefits of the changes
• Hold workers accountable
• Implement changes immediately

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Implementing CorrectiveAction Change

• To implement managements changes
• Retrain employees
• Relate changes to productivity
• Obtain approval and buy-in of upper management
• Monitor results

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Holding Employees Accountable

• Verbal warning
• Written warning
• Suspension
• Termination

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Summary

• Accidents dont just happen.
• The goal of accident investigation is to prevent
  accidents not place blame.
• The investigation process includes
• Determining accident facts
• Draw conclusions about the cause
• Develop safer ways to perform the task

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Questions?

Questions?
Questions?
Questions?
Questions?
Questions?
Questions?
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Accident Investigation Recognize Investigate

• SCF Arizona