ACCIDENT INVESTIGATION

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Presented by Donald L. Trussell DEP Safety
Program Administrator 850-488-0878 or SC 278-0878
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ACCIDENT INVESTIGATION

• The Basics

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Introduction

• BABYLONIAN LAW
• WHY PRACTICE SAFETY?
• SAFETY EXCELLENCE

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SAFETY CULTURE

• CULTURE
• PARK SAFETY CULTURE
• WAY OF LIFE
• TEAMWORK/PARTNERSHIP

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RISK

• DEFINITION
• IDENTIFY POTENTIAL PROBLEMS

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Responsibility/Accountability

• BASIC CONCEPT
• MEASURE PERFORMANCE
• ACCOUNTABILITY
• Put the I back in

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ACCIDENTS

• DONT JUST HAPPEN
• ARE THE LEADING CAUSE OF DEATH
• RESULT OF UNSAFE OR SUBSTANDARD ACTS AND
  CONDITIONS

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ACCIDENTS/INCIDENTS

• ACCIDENTS ARE INCIDENTS
• HAVE THE POTENTIAL TO HARM
• SHOULD ALWAYS BE INVESTIGATED

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What is an accident?

• An accident is..????

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An accident is

• Unwanted
• Unplanned
• Unforeseen
• Disruptive
• Can be major or minor

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Is an accident and an injury the same thing?

• NO!

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Obvious Injury Costs

• Insurance Premiums
• Medical Expenses
• Worker Compensation
• Rest of work crew takes up the slack
• Accident Cost Iceberg

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Hidden Injury Costs

• Lost time at work
• Reduced or lost income
• Pain and suffering
• Possibly having to learn a new job
• Training costs to the company
• Administrative costs (Investigation, ESH, HR)

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Actions vs. Attitudes

• Which is easier to see and report?

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Actions vs. Attitudes

• Which is easier to change?

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What we would like to see.

• That you understand why people do the things they
  do.
• That you know there are many factors that cause
  an accident.
• But mostlyThat you look deeply into why
  accidents happen!

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Why do we investigate??

• Prove the victim was at fault? ..no
• CYA .no
• Avoid law suits against the company.no
• Try to make the work place safer!!

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Accident Investigation An opportunity to change
the work climate by correcting unsafe conditions,
procedures, or actions.
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Elements of the Investigation

• Describe who was involved
• Describe what happened
• Establish a time line
• Determine location of accident all factors
• Establish a chain of events to understand how the
  accident occurred
• Determine the cause root cause

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First Goals of the Investigation

• Establish the following
• 1. Who
• 2. What
• 3. When
• 4. Where
• 5. How
• 6. Why

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Who

• Establish the person(s) who were involved in the
  accident, including witnesses. This includes all
  persons and not just an injured employee.

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What

• Describe in detail what happened.

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When

• Ensure times and dates are included in the
  statements.

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Where

• Get specific about the location, to include what
  Site, what facility, road name, etc.

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How

• Make sure your description of the incident is
  clear and describes the factors that caused the
  accident.

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Why

• Based on who/what/when/where/ how, you should be
  able to piece together why the accident happened.
  This involves piecing information together to
  form a conclusion of the cause root cause of
  the accident.

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Drawing Conclusions

• From the who/what/when/where/how why that you
  just gathered, you now need to determine both the
  cause and root cause of the accident.

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All things are hidden, obscure, and debatable
if the cause of the phenomena be unknown, but
everything is clear if this cause be
known.Louis Pasture
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Cause of the Accident

• The cause of the accident should describe what
  the immediate symptoms are of the accident.
• Example An employee slipped on the floor
  because there was spilled coffee that made the
  floor slippery.

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Root Cause

• The root cause of the accident is the basic
  underlying reason, not always apparent, that
  caused the accident.
• Example The root cause of the accident was that
  the person who spilled the coffee did not clean
  it up or establish a warning method to alert
  others of a hazard.

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Casual Factors Incident

• Precedes The loss
• Slip, Trip, Fall

• Loss Causation

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Causal FactorsBasic Causes

• THE DISEASE
• THIS IS THE WHY IT HAPPENED
• PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT
• PERSONAL JOB FACTORS

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Causal FactorsLack of Control

• STARTS THE SEQUENCE
• 3 WAYS TO GAIN CONTROL
• PROGRAM
• STANDARDS
• COMPLIANCE

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Multiple SourceCauses-Controls

• CHAIN
• 90/10 RULE
• 3 STAGES OF CONTROL
• PRE-CONTACT
• CONTACT
• POST CONTACT

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So how do I use this information when an accident
occurs?
?
?
?
?
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Begin Your Investigation

• Get the affected persons statement.
• Get onlookers statements.
• Note the positions of people and things.
• Gather other information as needed, like manuals,
  records of training, safety, and maintenance.
• Get pictures when needed (picture
  worth 1000 words)

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Interview Tips

• Need information - not placing blame.
• Try to form open ended, non-judgmental questions.
• Ask as many questions as it takes to clarify your
  understanding.

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Begin Your Written Report

• Gather all of your facts previously obtained, in
  particular who/what/when/where/how/why,
• and the cause/root cause of the accident.
• Additionally, gather written statements,
  information on similar incidents, and pictures to
  support your position when needed.

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Example of Fact GatheringOn July
29, 1999, on or about 1045 am, Joe Employee was
stacking concrete blocks and walked into a piece
of steel re-enforcing bar that was protruding out
of the end of the pipe storage shelving unit
located inside the Project Materials compound,
striking him in the face. A 1 cut was received
across the middle of Mr. Employees forehead. He
proceeded directly to the dispensary, where he
received 4 sutures to close the laceration, then
was released at 1141am in a full duty status.
He went to lunch, then informed his immediate
supervisor of the incident upon returning to work
at 1230.
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Your ConclusionsCause The accident was caused
by Joe not paying attention to his surroundings
and striking his head on the rebar.Root Cause
1 Somebody didnt properly store the rebar and
left it in a haphazard state that was obviously
unsafe.Root Cause 2 The supervisor has not
been taking responsibility for his work area by
monitoring for unsafe conditions.
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So Now What?

• At this point you have gathered facts,
  interviews, pictures, and all pertinent
  information. You have made conclusions and
  determined what the cause and root cause of the
  accident was.
• Question What do you do with this information?

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Corrective Action

• You take corrective action that would prevent the
  reoccurrence of this type of injury in the
  future, such as
• 1. You look around for similar things in your
  work center that would present the same type of
  hazard and implement corrective action.
  Examples pipe storage, lumber storage, conduit
  storage, etc.
• 2. You should counsel the work center supervisor
  on proper storage methods and his
  responsibilities.

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Finish Your Written Report

• Now write your conclusions (cause root cause)
  in your report, and finally wrap up your report
  by a Corrective Actions Taken paragraph.
  Attach all supporting documentation to the back
  of the report. You are now done with your
  written report.

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To Recap Your Investigation

• Who/what/when/where/how/why
• Conclusions (cause root cause)
• Corrective Actions Taken

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Uses of the Report

• 1. Toolbox Talks/Departmental Training
• 2. Use your written report to complete the
  Supervisors Accident Investigation Report

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Supervisors Accident Investigation Report

• Now that you have completed your written report,
  you are finally ready to complete the
  Supervisors Accident Investigation Report.
• This piece of paper is merely a standardized form
  to document your accident investigation. Filling
  out the form before doing an investigation is
  putting the cart before the horse and does not
  constitute an investigation.

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Why Investigate All Accidents and not just
Injuries?

• Because for every Serious Injury, there are
• Fatality
• 10 minor injuries
• 30 property damages
• 600 near misses
• So where should you be looking?

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Conclusion

• ATTITUDE
• AWARENESS
• RESOURCES

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Thats All Folks!