Investigating Accidents
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Marvin
Menesini
and Jim Rice
Course Objectives
- Recognize the
need for an investigation
- Investigate the
scene of the accident
- Interview victims
& witnesses
- Distinguish fact
from fiction
- Determine root
causes
- Compile data and
prepare reports
- Make recommendations
The Accident
What is an accident?
An unplanned, unexpected event that interferes with or interrupts normal
activity & potentially leads to personal injury or dollar loss (equipment
damage)
Basic Types of
Accidents
Minor Accidents
- Such as paper
cuts to fingers or dropping a box of materials.
More serious accidents
that cause injury or damage to equipment or property:
- Such as a forklift
dropping a load or someone falling off a ladder
Accidents that occur
over an extended time frame:
- Such as hearing
loss or an illness resulting from exposure to chemicals
Near-Miss
- Also know as
a Near Hit
- An accident that
does not quite result in injury or damage (but could have).
- Remember, a near-miss
is just as serious as an accident!
Accidents Have
Two Things in Common
- They all have
outcomes from the accident
- They all have
contributory factors that cause the accident
Outcomes of Accidents
- Negative aspects
- Injury &
possible death
- Disease
- Damage to
equipment & property
- Litigation
costs, possible citations
- Lost productivity
- Morale
- Positive aspects
- Accident
investigation
- Prevent recurrence
- Change to
safety programs
- Change to
procedures
- Change to
equipment design
The Aim of the Investigation
- The key result
should be to prevent a recurrence of the same accident.
- Fact finding:
- What happened?
- What was
the root cause?
- What should
be done to prevent recurrence?
The Aim of the Investigation
IS NOT TO:
- Exonerate individuals
or management.
- Satisfy insurance
requirements.
- Defend a position
for legal argument.
- Or, to assign
blame.
Tabletop exercise
- Review incident
provided
- Determine contributing
factors
- Determine root
causes
- Instructor will
answer questions
Types of Accidents
- Fall to
- Caught
- Contact with
- chemicals
- electricity
- heat/cold
- radiation
- Bodily reaction
from
- voluntary
motion
- involuntary
motion
- Struck
- Against
- stationary
or moving object
- protruding
object
- sharp
or jagged edge
- By
- moving
or flying object
- falling
object
- Rubbed or abraded
by
- friction
- pressure
- vibration
A step-by-step process
(almost)
Investigation Strategy
- Gather information
- Search for &
establish facts
- Isolate essential
contributing factors
- Find root causes
- Determine corrective
actions
- Implement corrective
actions
Secure the Scene
- Eliminate the
hazards:
- Control chemicals
- De-energize
- De-pressurize
- Light it
up
- Shore it
up
- Ventilate
Provide Care to the Injured
- Ensure that medical
care is provided to the injured people before proceeding with the investigation.
Isolate the Scene
- Barricade the
area of the accident, and keep everyone out!
- The only persons
allowed inside the barricade should be Rescue/EMS, law enforcement,
and investigators
- Protect the evidence
until investigation is complete
Ask What Happened
- Get a brief overview
of the situation from witnesses and victims.
- Not a detailed
report yet, just enough to understand the basics of what happened.
Interview Victims
& Witnesses
- Interview as
soon as possible after the incident
- Do not interrupt
medical care to interview
- Interview each
person separately
- Do not allow
witnesses to confer prior to interview
The Interview
- Put the person
at ease.
- People may
be reluctant to discuss the incident, particularly if they think
someone will get in trouble
- Reassure them
that this is a fact-finding process only.
- Remind them
that these facts will be used to prevent a recurrence of the incident
- Take Notes!
- Ask open-ended
questions
- What did you
see?
- What happened?
- Do not make suggestions
- If the person
is stumbling over a word or concept, do not help them out
- Use closed- ended
questions later to gain more detail.
- After the
person has provided their explanation, these type of questions can
be used to clarify
- "Where were
you standing?"
- "What time
did it happen?"
- Dont ask
leading questions
- Bad: Why
was the forklift operator driving recklessly?
- Good: How
was the forklift operator driving?
- If the witness
begins to offer reasons, excuses, or explanations, politely decline
that knowledge and remind them to stick with the facts
- Summarize what
you have been told.
- Correct misunderstandings
of the events between you and the witness
- Ask the witness/
victim for recommendations to prevent recurrence
- These people
will often have the best solutions to the problem
- Get a written,
signed statement from the witness
- It is best
if the witness writes their own statement; interview notes signed
by the witness may be used if the witness refuses to write a statement
Interview Exercise
- Read the scenario
handout
- Team up in pairs
- One person plays
the investigator
- One person plays
the witness
Gather Evidence
- Examine the accident
scene. Look for things that will help you understand what happened:
- Dents, cracks,
scrapes, splits, etc. in equipment
- Tire tracks,
footprints, etc.
- Spills or
leaks
- Scattered
or broken parts
- Etc.
- Diagram the scene
- Use blank
paper or graph paper. Mark the location of all pertinent items;
equipment, parts, spills, persons, etc.
- Note distances
and sizes, pressures and temperatures
- Note direction
(mark north on the map)
- Take photographs
- Photograph
any items or scenes which may provide an understanding of what happened
to anyone who was not there.
- Photograph
any items which will not remain, or which will be cleaned up (spills,
tire tracks, footprints, etc.)
- 35mm cameras,
Polaroid's, and video cameras are all acceptable.
Digital
cameras are not recommended - digital images can be easily altered
Review Records
- Check training
records
- Was appropriate
training provided?
- When was
training provided?
- Check equipment
maintenance records
- Is regular
PM or service provided?
- Is there
a recurring type of failure?
- Check accident
records
- Have there
been similar incidents or injuries involving other employees?
Isolate Fact From
Fiction
- Use NORMS- based
analysis of information
- Not
an interpretation
- Observable
- Reliable
- Measurable
- Specific
- If an item meets
all five of above, it is a fact.
Norms
of Objectivity
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Objective
Not
an Interpretation Based on a factual description.
Observable based on what is seen or heard.
Reliable Two or more people independently agree
on what they observed.
Measurable a number is used to describe behavior
or situation.
Specific based on detailed definitions of what happened.
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Subjective
Interpretations
based on personal interpretations/ biases.
Non- observable based on events not directly observed.
Unreliable Two or more people dont agree on
what they observed.
Non- measurable a number isnt used.
General based on non-detailed descriptions.
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Investigation
Traps
- Put your emotions
aside!
- Dont
let your feelings interfere - stick to the facts! ( T
he E yes G lazed O ver)
- Do not pre- judge.
- Find out
the what really happened.
- Do not let
your beliefs cloud the facts.
- Never assume anything.
- Do not make any
judgments.
Contributing Factors
- Environmental
- Design
- Systems &
Procedures
- Human Behavior
- Common to
all accidents
- Not limited
to the person involved in the accident
- Environmental
- Noise
- Vapors, fumes,
dust
- Light
- Heat
- Critters
- Design
- Workplace
layout
- Design of
tools & equipment
- Maintenance
- Systems &
Procedures
- Lack of systems
& procedures
- Inappropriate
systems & procedures
- Training
in procedures
- Housekeeping
Contributing Factors
Investigation Strategy
- Isolate essential
contributory
- Investigation
team
- Evaluates
all factors concerned
- Isolate essential
contributory factors
- Investigation
team
- Isolates
the key factor(s) by asking the following question....
Would the accident
have happened if this particular factor was not present?
Determine Causes
- Employee actions
- Safe behavior,
at- risk behavior
- Environmental
conditions
- Lighting,
heat/ cold, moisture/ humidity, dust, vapors, etc.
- Equipment condition
- Defective/
operational, guards, leaks, broken parts, etc.
- Procedures
- Existing
(or not), followed (or not), appropriate (or not)
- Training
- Was employee
trained - when, by whom, documentation
Find Root Causes
- When you have
determined the contributing factors, dig deeper!
- If employee
error, what caused that behavior?
- If defective
machine, why wasnt it fixed?
- If poor lighting,
why not corrected?
- If no training,
why not?
Prepare a Report
- Accident Reports
should contain the following:
- Description
of incident and injuries
- Sequence
of events
- Pertinent
facts discovered during investigation
- Conclusions
of the investigator( s)
- Recommendations
for correcting problems
- Be objective!
- State facts.
- Assign cause(
s), not blame.
- If referring
to an individuals actions, dont use names in the recommendation.
- Good:
All employees should
.
- Bad:
George should
..
Make Recommendations
- Determine corrective
actions
- Investigation
team
- Interprets
& draws conclusions
- Distinction
between intermediate & underlying causes
- Recommendations
based on key contributory factors and underlying/ root causes
- Recommendation(
s) must be communicated clearly and objectively.
- Strict
time table established
- Follow
up conducted
Company Accident
Forms
- Must be filled
out completely by the employee and employees immediate supervisor
(this includes foremen).
- Must be turned
in to Safety within 24 hours of incident.
Benefits of Accident
Investigation
- Preventing recurrence
- Identifying out-moded
procedures
- Improvements to
work environment
- Increased productivity
- Improvement of
operational & safety procedures
- Raises safety
awareness level
When an organization
reacts swiftly and positively to accidents and injuries, its actions reaffirm
its commitment to the safety and well-being of its employees
THANK YOU!
- Remember, always
dig deep for the answers.
- Dont suffer
from TEGO!
What Have You
Learned?
- Final Exercise!
- Review incident
provided
- Determine contributing
factors
- Determine root
causes
- Present report
This paper appears in the eLCOSH website with the permission of the author
and/or copyright holder and may not be reproduced without their consent.
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