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ACCIDENT INVESTIGATION

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Incident An event which could or does result in unintended harm or damage ... Almost unbelievable. Series. Of unlikely events 5. Non absence 5 ... – PowerPoint PPT presentation

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Title: ACCIDENT INVESTIGATION


1
ACCIDENT INVESTIGATION
2
Definitions Accident An event that results in
unintended harm or damage Incident An event
which could or does result in unintended harm
or damage Investigation A systematic inquiry into
an event Safety Control of accidental loss
3
The Cost of Accidents
Insured Costs
Employers Liability Public Liability
Damage
Business disruption Product Liability

Direct Costs
Indirect Costs
Sick Pay Repairs
Products damaged
Investigation Costs Loss of
Good Will Hiring/Training replacement staff
Corporate image
Product Liability
Uninsured Costs
4
The Cost of Accidents at DMUK
2004/2005 26 Lost Time Accidents
388 Days lost due to accidents
5,133 paid is SSP (13.23
per day) 13,855 paid in Co. sick pay
(13K salary)
14,938 temporary labour cover
(5.50ph)
Total 33,926 ( hidden costs)
2005/2006 16 Lost Time Accidents
159 Days lost due to
accidents 2,169 paid is
SSP (13.64 per day) 8,611 paid
in Co. sick pay (13K salary) 6,558
temporary labour cover (5.50ph) Total
17,338 ( hidden costs)
5
The Cost of Accidents at DMUK
A large UK insurer estimates that a non-absence
accident costs approximately 315 DMUK 2004/2005
211 accidents _at_ 315 66,465 DMUK 2005/2006
165 accidents _at_ 315 51,975
6
Relationship between Injury, Damage Near Miss
Previously organisations have concentrated on
investigating only injury or lost time accidents.
All Incidents should be investigated as it is
likely that it was only by chance that there
wasnt an injury.
By reducing the number of near misses, where no
injury was sustained, we can hope to reduce the
numbers of damage, minor and more serious
incidents. This
confirms the importance of investigating ALL
accidents/incidents. All represent failures in
safety management and have valuable learning
opportunities
7
Accident Investigation
  • Why Investigate Accidents ?
  • Monitor the effectiveness of the HS Policy
  • Create information for statistical trend
    analysis
  • Determine accident causation
  • Develop actions / countermeasures
  • Prevent reoccurrence
  • Improve systems, procedures awareness learn
    from events
  • Legislative requirement
  • Management System / Audit requirements (OHSAS
    18001)
  • Allow / ensure continuous improvement

8
Accident Investigation - Causation
Accidents, incidents Ill-health are never
random events. They arise from failures of
control and often involve multiple contributory
elements. Immediate causes may be deemed as human
error of equipment failures, but such problems
often arise from underlying organisational
failures that are the responsibility of Senior
Management.
9
Accident Investigation - Causation
Job Factors Including the adequacy of the
workplace precautions for the premises, plant
substances involved and the procedures systems
of work
Immediate/Basic Causes
Personal Factors Including the behaviour,
suitability competence of those doing the work
Job
Person (s)
Organisation Management
Underlying Causes
  • Management Organisational Factors
  • Adequacy of HS Policy
  • How work controlled, co-ordinated supervised
  • How co-operation involvement of Associates
    achieved
  • Adequacy of HS communications
  • Adequacy of audit and review arrangements
  • How competency achieved, tested evaluated
  • Adequacy of planning, risk assessment and the
    design of risk control measures
  • Adequacy of measuring monitoring activity

10
Immediate Causes
  • Failure to warn
  • Failure to follow rules procedures
  • Removing safety devices
  • Improper handling
  • Failure to use PPE
  • Running / rushing
  • Taking risks / shortcuts
  • Horseplay

Substandard / Unsafe Acts or Practices
  • Inadequate guards barriers
  • Inadequate PPE
  • Defective tools equipment
  • Congestion / obstruction
  • Inadequate lighting
  • Trailing cables
  • Uneven surfaces
  • Slippery floors

Substandard Conditions
11
Basic Causes
  • Inadequate physical capability
  • Inadequate mental capability
  • Lack of knowledge
  • Lack of skill
  • Stress

Personnel Factors
  • Inadequate leadership
  • Inadequate supervision
  • Inadequate tools equipment
  • Inadequate maintenance
  • Inadequate work standards
  • Wear tear

Job/System Factors
12
Root Causes
  • Management Organisational Factors
  • Inadequate systems/procedures/standards
  • Inadequate training
  • Inadequate communications
  • Inadequate assessment control of risk

13
Accident Investigation - Example
Man Falls from Ladder Not following procedure
Man Falls from Ladder Uneven surface
Immediate Causes
Possible Basic Causes
  • Possible Root Causes / Organisational Failures
  • Lack of training provided in inspections/use of
    ladders
  • Lack of resources to identify correct ladder
    standards specifications
  • Lack of management commitment to proper time,
    planning, risk control
  • Inadequate maintenance procedure for work
    equipment

Establishing Root Causes allows us to learn
from our mistakes and not mask the problem
14
Who should investigate?
  • Designating an investigator or investigating team
    is critical to ensure a truthful and relevant
    investigation and outcome.
  • Personnel who might be involved include
  • Injured person
  • Witnesses
  • First line supervisor/Team Leader
  • Senior/Middle Manager
  • Safety Specialists
  • Health Safety Promoters
  • Experts
  • External agencies

15
Conducting Investigations
  • Good investigations are prompt and thorough. If
    investigations are not completed quickly after an
    event, conditions and peoples memories may fade.
  • Effective investigations include the following
    basic activities
  • Respond quickly
  • Gather as much information as possible
  • Analyse causes
  • Take remedial action
  • Complete all appropriate documentation
  • Ensure management follow-up

16
Respond Quickly at the scene
  • The Line Management or Manager for the area will
    be expected to take the lead, organise and
    control initial actions
  • Take control at the scene. Ensure 1st aid
    emergency actions
  • Control prevent potential secondary incidents
    by ensuring the area is safe
  • Identify sources of evidence (materials,
    equipment, witnesses)
  • Preserve evidence from alteration or removal
  • Determine the loss potential
  • Notify appropriate personnel and agencies (HS
    department, Environmental department, HSE etc)

17
Information Gathering/Collecting Evidence
  • A great deal of information will be available for
    every incident. The priority is to find and
    concentrate on the most important aspects.
  • Information you will need for a suitable
    sufficient investigation will include
  • Facts about the casualty (name, clock no., job,
    injuries etc)
  • Accident location, date and time
  • Visual look at and information about accident
    environment
  • Establish exact sequence of events leading up to
    accident
  • Identify all equipment involved
  • Identify any witnesses and take statements
  • Identify any unsafe conditions (floors, stairs,
    machinery, lighting etc)
  • Take photographs and measurements if required
  • Identify if risk assessments SSOW are available
  • Identify root causes

18
Information Gathering/Collecting Evidence
  • Documents
  • Written instructions, procedures, risk
    assessments, policies etc
  • Records of earlier inspections, tests,
    examinations surveys
  • Observation
  • Information from physical circumstances,
    including
  • Premises place of work
  • Access egress
  • Plant substances in use
  • Location relationship of physical parts
  • Any post-event checks, test, sampling or
    reconstruction
  • Checking Reliability, accuracy
  • Identifying conflicts resolving differences
  • Identifying gaps in evidence
  • Interviews information from
  • Those involved their line management
  • Witnesses
  • Those observing or involved before event
    (maintenance etc)

19
Analysing Information
  • Review all the information you have gathered
    during the investigation
  • Analyse the information in order to determine
    both immediate, basic and root causes of the
    accident/incident
  • Analysis must be based on FACTUAL information,
    not supposition
  • Ensure that findings are justifiable and can be
    backed up by relevant information

Conclusions
  • From the information and evidence gathered make
    your conclusions as to the factors that
    contributed to the accident/incident
  • Conclude as to whether these are personal
    factors pertinent to the individual or job/system
    factors relating to some part of the management
    system or process (remember, they can be both)
  • Conclusions sill help determine appropriate
    countermeasures

20
Countermeasures Remedial Action
  • Consider what actions need to be taken to
    prevent reoccurrence of the situation
  • These may include short, medium and long term
    countermeasures
  • Countermeasures may be physical (machine
    guarding or alterations) or non-physical
    (additional training, instruction etc) or both
  • Responsibility for each countermeasure must be
    assigned to an individual and a date given for
    completion
  • Following each action date the items should be
    checked and confirmed as being completed before
    the investigation can be signed off as fully
    complete
  • Once completed the Risk Assessment SSOW should
    be reviewed and amended as appropriate
  • There would normally be 2 or 3 countermeasures
    per accident/incident as a minimum

21
Communication
  • It is vital that once the investigation has taken
    place that the findings and agreed actions be
    communicated to all relevant Associates
  • SIB
  • Team Briefings
  • Toolbox Talks
  • News Bulletin
  • Additional training and instruction may be
    required if the risk assessment/SSOW has been
    amended (this must be recorded). Associates
    cannot be expected to be aware of the dangers or
    controls if they do not receive the appropriate
    communications
  • In addition for auditing purposes and in
    mitigation of prosecution or civil claims we must
    be able to show records of appropriate
    communication, information, instruction
    training relating to accidents

22
Accident Investigation at DMUK
Using the following table the Potential Severity
Rating must be determined for each
accident/incident in order to confirm the level
of investigation required
23
Potential Severity Degree of Investigation
Using the following determine the Potential
Severity Rating and the level of investigation
required
24
Requirements of Investigation
25
DMUK Investigations
Departmental Investigations Level of
investigation used for all accidents with
potential severity rating of between 48 and 60
and for all Lost Time accidents
Panel Of Enquiry (No Major Injury) Level of
investigation used for all accidents with
potential severity rating of 61 and above

Panel Of Enquiry (Major Injury) Level of
investigation used for all accidents with
potential severity rating of 61 and above

26
Efficient Effective Investigations
PREVENT REOCCURRENCE IMPROVE AWARENESS IMPROVE
SYSTEMS IMPROVE PROCEDURES PROVIDE VALUABLE
LEARNING OPPORTUNITIES
27
Accident Investigation Key Messages
  • ALL accidents/incidents must be investigated
  • ALL accidents/incidents represent failures
    management/organisation
  • ALL accidents/incidents have valuable learning
    opportunities
  • Accidents often involve multiple contributory
    elements
  • Consider immediate, basic and root causes during
    accident investigation
  • To ensure a good investigation Respond quickly
  • Gather as much information as possible
  • Analyse causes
  • Take remedial action
  • Complete all appropriate documentation
  • Ensure effective management follow-up
  • Communicate event
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