Dumb

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Dumb Dumber!
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The Safety Policy covers falling off the
scaffold, all right but according to our
investigation, you never hit the ground.
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ACCIDENT INVESTIGATION
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Goals

• Participants will learn
• What an accident is
• The value of investigating accidents
• Methods of investigation
• Interviewing techniques
• Analysis techniques

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WHAT IS AN ACCIDENT?

• What is an accident?
• Any unexpected event
• Some may even be good
• Does an accident always involve an injury?
• Does an injury always involve an accident?

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What Is An Accident?
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Accidents

• Accident
• Any unplanned event that results in
• Personal injury
• Property damage

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Accidents

• Usual causes
• Failure of people, equipment, supplies, or
  surroundings to behave or react as expected

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WHY INVESTIGATE?

• Why investigate?
• To PREVENT injuries
• Investigations should not be witch hunts
• If results show need for discipline, fine
• But.....
• That is not the purpose

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INVESTIGATIONS

• Include non injury accidents
• Proactive
• Preventative
• Investigating only injuries
• Reactive

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Benefits of Investigating Accidents

• Increased production
• Higher morale
• Reduced insurance costs
• Evaluation of work practices, conditions
• Improved policies and procedures
• Improved supervision
• Healthier employees
• Shows management commitment

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INJURY PYRAMID
Fatality
Serious Recordable
Recordable
1st Aid Cases
Non-injury Accidents
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Accident Investigation Plan

• Establish guidelines, responsibilities,
  accountability
• Establish notification and response procedures
• Mandate early, immediate, reporting of all
  accidents
• Establish procedures to preserve and secure
  accident sites

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Accident Investigation Plan

• Develop forms
• Accident report form
• Investigation forms
• May have different forms based on level of
  investigation
• Recommendation form
• Formal report
• Train employees

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First Report

• The First Report of Injury sent to Workers
  Compensation Company is NEITHER an accident
  report NOR an investigation.

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Accident Report

• Write an accident report
• As soon as possible
• Start with a supervisors report based on
  information provided by employees
• Employee said......

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Accident Report

• Date, time, place of accident
• Date time reported
• Date of this report
• Injury (if any)
• Specific body part, e.g. left thumb, right foot,
  etc.
• Preliminary description of type of injury, e.g.
  cut, bruise, fracture, etc.,

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Accident Report

• Property damage, if any
• Be specific
• Description of what happened
• Names of witnesses
• Any other pertinent information
• Signature of supervisor

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Accident Report

• Review by manager
• Refer immediately for investigation
• Safety committee
• Management investigation team
• Employee investigation team
• Combination
• Independent investigation team

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Exercise 1

• Accident Report

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Injury Potential

• Investigate based on POTENTIAL FOR INJURY
• The greater the potential, the more thorough the
  investigation

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The Investigation

• Begin investigating as soon as possible.
• Avoid a cold trail

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Accident Investigation Kit

• Have investigation tools readily available

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Accident Investigation Kit

• Camera film still, digital, video
• Clipboard, paper, pencils/pens
• Copies of regulations, policies, JSAs
• Gloves, other PPE needed to enter area

• Recorder, blank tapes, batteries
• Flashlight,batteries
• Graph paper
• Ruler, tape measure
• Plastic bags
• Identification tags
• Compass

Any combination as appropriate
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The Investigation

• Be methodical
• Gather as much information as possible
• Throw out irrelevant information during the
  analysis step

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The Investigation

• Beware of preconceived conclusions
• Beware of jumping the gun
• Do not offer solutions before you find the basic
  cause

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The Investigation

• ASK QUESTIONS
• When you get an answer, ask WHY
• Then ask WHY again
• And AGAIN
• And who?, what?, and ...why?

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The Investigation

• Find root cause
• Dont settle for carelessness, not paying
  attention, etc.
• There is more to it

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The story goes that when the dude at the top of
the ladder was challenged, his reply was, "I'm a
licensed electrician, so what's your problem?"
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The Investigation

• Try to find reason for behavior
• Illness?
• Vacation coming up?
• Problems at home?
• Daydreaming?
• Drugs, alcohol?
• Complacency?
• Find the real reason

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Management Safety Policies Decisions
Personal Factors
Environmental Factors
Basic Causes
Indirect Causes
Unsafe Act
Unsafe Condition
Direct Causes
Unplanned Release of Energy and/or Hazardous
Material
ACCIDENT
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The Investigation

• Interview employee involved
• Interview witnesses
• Interview other employees in area
• Look for similar incidents

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The Investigation

• Investigate the scene
• Take measurements
• Take pictures
• Evaluate equipment
• Be imaginative

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The Investigation

• Look for
• Guards off
• Lack of PPE
• Housekeeping issues
• Poor work practices
• Faulty equipment
• Inadequate training
• Poorly written procedures
• Etc.

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The 4 Ps

• People
• Position
• Parts
• Paper

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People

• Observation and memory
• Fragile - changes
• With time
• With discussions
• Personality factors

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Exercise 2

• Observation

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Position

• Location
• Weather
• Roadway/aisleway/path
• Operating location
• Direction of travel
• Wreckage resting position

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Parts

• Failed machinery
• Communication system failures
• Inadequate/improper equipment support or guarding
• Fuels, lubricants
• Debris at site

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Paper

• Records
• Publications
• Tapes, videos
• Directives, policies
• Drawings
• Plans
• Reports

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Exercise 2-A

• Observation

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Interviews

• Get preliminary statements as soon as possible
  from
• All witnesses
• Other employees in area
• Locate position of each person on a master chart
  including direction of view.

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Interviews

• Explain the purpose of the investigation
• Accident prevention
• Put at ease
• Let speak freely
• Take notes without distracting
• Only use a tape recorder with the persons
  knowledge and consent.

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Interviews

• Use sketches and diagrams
• Emphasize areas of direct observation
• Label hearsay accordingly
• Record the exact words to describe each
  observation.

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Interviews

• Word each question carefully, and be sure the
  person understands.
• Be careful not to put words into the witnesss
  mouth.
• Identify the qualifications
• Name, address, occupation, years of experience,
  etc. as appropriate

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Exercise 3

• Interviews

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Analysis Techniques

• Change analysis
• Job Safety Analysis (JSA)
• Event and Causal Factors Analysis
• Multi linear Events Sequencing (MES)
• Project Evaluation Tree (PET)
• Combination

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Change Analysis

• Emphasizes change
• Look for deviations from the norm
• Consider all problems to result from some
  unanticipated change.
• Make an analysis of the change to determine its
  causes.
• Use the following steps

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Change Analysis

• Define the problem
• What happened?
• Establish the norm
• What should have happened?
• Identify, locate, and describe the change
• What, where, when, to what extent

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Change Analysis

• Specify what was and what was not affected.
• Identify the distinctive features of the change.
• List possible causes.
• Select the most likely causes.

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Job Safety Analysis

• JSA is part of many existing accident prevention
  programs.
• A JSA
• Breaks a job into basic steps
• Identifies the hazards associated with each step
• Prescribes controls for each hazard
• A JSA is a chart listing these steps, hazards,
  and controls.

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Job Safety Analysis

• If there is an existing JSA for the job involved
  in the accident
• Review it during the investigation
• If there is no JSA available
• Develop one
• A JSA can help determine the events and
  conditions that led to the accident.

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Event Causal Factors Analysis

• Thorough collection of all information
• In depth evaluation of information
• Determine cause and effect factors
• Detailed narrative

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Report of Investigation

• Prepare and submit a formal report which includes
  the following
• 1. Background information
• a. Where and when the accident occurred
• b. Who and what were involved
• c. Operating personnel and other witnesses

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Report of Investigation

• 2. Account of the accident
• a. Sequence of events
• b. Extent of damage
• c. Accident type
• d. Agency or source of energy or hazardous
  material

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Report of Investigation

• 3. Discussion (Analysis of accident)
• a. Direct causes (energy sources, hazardous
  materials)
• b. Indirect causes (unsafe acts, unsafe
  conditions)
• c. Basic causes (management policies, personal
  factors, environmental factors)

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Report of Investigation

• 4. Recommendations for prevention, immediate and
  long-range
• a. Basic causes
• b. Indirect causes
• c. Direct causes

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Exercise 4

• Investigation

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RESOLUTION

• Discuss ways of preventing future incidents
• Solicit ideas from employees others
• Be creative
• Make recommendations

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Recommendations

• Recommendations
• Changes likely to prevent future occurrences or
  reduce effects
• Use Hierarchy of Controls to assist in making
  recommendations
• Eliminate hazard
• Control hazard
• Policies and procedures
• PPE

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Corrective Actions

• Corrective actions
• Recommendations that are adopted
• Inform and train employees and supervisors

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Follow-Up

• Involve supervisors employees
• Are solutions
• Used?
• Effective?
• Solicit feedback

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Trend Analysis

• Evaluate for accident and injury trends in order
  to focus efforts
• Use 200 300 forms, accident reports, first aid
  logs, inspection reports, etc.
• Analyze by entity, facility, time, job, etc.
• Do at least a 3 year comparison

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Resource

• Ask for help from your workers compensation
  carrier

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QUESTIONS
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Thank You
Sandra A. Mihalik, WSO-CST Safety Health
Supervisor Montana Safety Health Bureau Phone
406/444-6418 E-mail smihalik_at_state.mt.us