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Accident Investigation DuAll Safety Richard DeBusk

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An unplanned event that results in personal injury or in property damage. Also called 'Incident' or 'Mishap' Near miss. 3. Accident Investigation ... – PowerPoint PPT presentation

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Title: Accident Investigation DuAll Safety Richard DeBusk


1
Accident InvestigationDu-All SafetyRichard
DeBusk
2
What is an Accident?
  • An unintended happening with __________ results
  • An unplanned event that results in personal
    injury or in property damage
  • Also called Incident or Mishap
  • Near miss

3
Accident Investigation
  • Most important-Investigation is not intended to
    place blame.
  • Determine how and why of failures
  • Examine possible corrective action
  • Aid in the accident prevention and elimination of
    a clearly identified hazard
  • Critique of emergency response may or may not be
    included, but should be if it actually
    contributed to the incident
  • (e.g., the fire extinguishers were empty)

4
The Three Basic Causes
Equipment and Materials Personnel Processes and
Procedures
Basic Causes
ACCIDENT Personal Injury Property Damage
Unsafe Condition
Unsafe Act
Unplanned Event
5
Immediately
  • Protect yourself
  • Protect evidence
  • Identify witnesses
  • Document the accident scene before any changes
    are made
  • Take photos
  • Draw sketchesscaled if possible
  • Record measurements

6
Record the Facts
  • Even the most insignificant detail may be useful
  • Document and then document some more

7
Record the Facts (cont.)
  • Interview witnesses as soon as possible
  • Gather support data such as
  • maintenance records
  • training records
  • production schedules
  • process diagrams
  • weather and rainfall
  • etc.

8
Record the Facts (cont.)
  • Record
  • Pre-accident conditions
  • Accident sequence
  • Post-accident conditions
  • Document victim location, witnesses, machinery,
    energy sources and other relevant factors

9
Interviewing
  • First-hand knowledge
  • May present pitfalls in the form of embellishment
    or withholding
  • Bias Perspective
  • Protecting self or others
  • Overly-helpful

10
Interviewing
  • Identify all witnesses
  • Separate witnesses
  • Explain the purpose of the investigation and put
    each witness at ease
  • Get preliminary statements as soon as possible
    from all witnesses
  • Locate the position of each witness on a master
    chart (including the direction of view)

11
Interviewing (cont.)
  • Let each witness speak freely
  • Ask clarifying questions if needed, but do not
    lead
  • Use a tape recorder only with consent of the
    witness
  • Take detailed notes
  • Use sketches and diagrams to help the witness
  • Emphasize areas of direct observation and label
    hearsay accordingly
  • Unless youve taped the interview, review your
    notes with the witness and have them verify that
    they are accurate

12
Interviewing QuestionsAsk Open-Ended Questions,
Not Leading Questions
  • Not Did you see the car hit the victim?
  • But What did you see?
  • Not Was the valve closed?
  • But What was the position of the valve?
  • Not Were you distracted by something just
    before the accident?
  • But What were you doing just before the
    accident?

13
Interviewing Questions What would be better
questions than the following?
  • Were you taught not to use that tool on that
    material?
  • Was the victim wearing the right kind of shoes?
  • Did it sound like a hissing noise?
  • Did you have a hangover?

14
Finding the Cause
  • There are many techniques that can be used
  • Fault Tree
  • Change Analysis
  • MORT (Management Oversight and Risk Tree)
  • TOR (Technique of Operations Review)
  • Ishikawa
  • Hartford
  • Etc.
  • There is no one right method, even within a given
    investigation

15
Finding the CauseChange Analysis
  • Considers all problems to result from some change
  • Work backwards in time
  • Examine deviations from the norm
  • Analyze the changes to determine their cause and
    effect

16
Finding the CauseChange Analysis (cont.)
  • Shortcomings
  • Focuses on processes and equipment
  • Sometimes hard to use for behavior-based causes
  • Sometimes hard to use for combined/probabilistic
    causes

17
Finding the CauseChange Analysis (cont.)
  • Use the following steps in this method
  • Define the problem (What sequence of events
    happened?)
  • Establish the norm (What sequence of events
    should have happened?)
  • Identify, locate, and describe the change (What,
    where, when, to what extent)
  • Specify what was and what was not affected
  • List the possible causes
  • Select the most likely causes

18
Finding the CauseEPP (Equipment-People-Process)
  • Considers all problems to result from some
    combination of
  • Equipment Materials
  • People
  • Processes Procedures

19
Finding the CauseEPP (cont.)
  • For each box, consider the who, what, where,
    when and why?

20
Investigation Report
  • An accident investigation is not complete until a
    report is prepared and submitted to the proper
    authorities
  • Report may include reports from other agencies
    such as police or fire
  • Your report may become evidence

21
Investigation Report
  • Background Information
  • Where and when the accident occurred
  • Who and what were involved
  • Operating personnel and other witnesses
  • Outside agencies that responded
  • Account of the Accident (What happened?)
  • Sequence of events
  • Extent of damage, loss, injury
  • When investigating a Near Miss, report potential
    outcomes of the worst credible case incident

22
Investigation Report (cont.)
  • Discuss causes of incident
  • Recommend changes
  • Short and long term
  • Prevention of re-occurrence
  • Readiness for future such emergencies, if
    appropriate

23
Practice Accident 1
  • Police officer closed own hand in car door

24
Practice Accident 2
  • Operator opened the lid of a spray cleaner used
    for automatically cleaning parts. Solvent was
    sprayed in operators eyes

25
Accident Prevention
26
Steps in preventing reoccurrence
  • Be sure incidents are reported
  • Perform root cause analysis
  • Based on root cause(s), recommend actions that
    will keep the root cause(s) from happening again.

27
Root Cause Analysis
  • If you havent identified the true root cause,
    you cant properly identify preventive measures.
  • Or, said another way
  • If you identify the wrong root cause, your
    preventive measures wont work.

28
Preventive Measures
  • They must be
  • PracticalCan they be done?
  • EffectiveWill they work?
  • ProductiveCan we get our jobs done?
  • Otherwise, the accident may be unpreventable.
  • BUT . . . You are not responsible for
    inexpensive.

29
Preventive MeasuresOK, weve identified the
Root Cause, now lets make recommendations
30
Example Slip and Fall
  • Incident
  • Employee stepped on accumulated debris of pine
    cones and needles. Employee twisted ankle and
    fell.
  • NOTE Supervisors report describes this as
    non-preventable.
  • Questions to ask?

31
Example Slip and Fall
  • Questions
  • What was the employees condition, i.e., relative
    to attentiveness and/or agility?
  • What was the actual condition of the walking
    surface?

32
Example Slip and Fall
  • Possible recommendations, based on Root Cause
  • Increase frequency of cleaning this walking
    surface.
  • Signage.
  • Practical? Effective? Productive?

33
Example 2 Fall from ladder
  • While standing on a ladder to wash window,
    employee leaned out too far ladder slipped,
    causing employee to fall.
  • Supervisors statement Employee should move
    ladder close to work. Will review at division
    Safety Meeting.

34
Example 2 Fall from ladder
  • Other possible Root cause analysis questions
  • Equipment Condition? Arrangement?
  • Employee Training? Motivation?

35
Any Questions
  • ??
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