Summary Statement
A presentation for a course on accidents, including definitions of accidents, and information on how to identify and handle them and how to find out what really happened
How to find out what really happened.
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.
- Such as a forklift dropping a load or someone falling off a ladder
- Such as hearing loss or an illness resulting from exposure to chemicals
- 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
- Injury &
possible death
- Positive aspects
- Accident
investigation
- Prevent recurrence
- Change to
safety programs
- Change to
procedures
- Change to equipment design
- Accident
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?
- What happened?
- Exonerate individuals
or management.
- Satisfy insurance
requirements.
- Defend a position
for legal argument.
- Or, to assign blame.
- Review incident
provided
- Determine contributing
factors
- Determine root
causes
- Instructor will answer questions
- Fall to
- same level
- lower level
- same level
- Caught
- in
- on
- between
- in
- Contact with
- chemicals
- electricity
- heat/cold
- radiation
- chemicals
- Bodily reaction
from
- voluntary
motion
- involuntary
motion
- voluntary
motion
- Struck
- Against
- stationary
or moving object
- protruding
object
- sharp or jagged edge
- stationary
or moving object
- By
- moving
or flying object
- falling object
- moving
or flying object
- Against
- Rubbed or abraded
by
- friction
- pressure
- vibration
- friction
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
- Eliminate the
hazards:
- Control chemicals
- De-energize
- De-pressurize
- Light it
up
- Shore it
up
- Ventilate
- Control chemicals
Provide Care to the Injured
- Ensure that medical care is provided to the injured people before proceeding with the investigation.
- 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
- 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 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
- Put the person
at ease.
- People may
be reluctant to discuss the incident, particularly if they think
someone will get in trouble
- 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?”
- What did you
see?”
- Do not make suggestions
- If the person
is stumbling over a word or concept, do not help them out
- 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?"
- Don’t ask
leading questions
- Bad: “Why
was the forklift operator driving recklessly?”
- Good: “How
was the forklift operator driving?”
- Bad: “Why
was the forklift operator driving recklessly?”
- 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
- 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.
- Dents, cracks,
scrapes, splits, etc. in equipment
- 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)
- Use blank
paper or graph paper. Mark the location of all pertinent items;
equipment, parts, spills, persons, etc.
- 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
- Photograph
any items or scenes which may provide an understanding of what happened
to anyone who was not there.
Review Records
- Check training
records
- Was appropriate
training provided?
- When was
training provided?
- Was appropriate
training provided?
- Check equipment
maintenance records
- Is regular
PM or service provided?
- Is there
a recurring type of failure?
- Is regular
PM or service provided?
- 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
- Not
an interpretation
- If an item meets all five of above, it is a fact.
Norms
of Objectivity
|
|
Objective Not
an Interpretation – Based on a factual description. |
Subjective Interpretations
– based on personal interpretations/ biases. |
Investigation
Traps
- Put your emotions
aside!
- Don’t
let your feelings interfere - stick to the facts! ( T
he E yes G lazed O ver)
- Don’t
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.
- Find out
the what really happened.
- 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
- Common to
all accidents
- Environmental
- Noise
- Vapors, fumes,
dust
- Light
- Heat
- Critters
- Noise
- Design
- Workplace
layout
- Design of
tools & equipment
- Maintenance
- Workplace
layout
- Systems &
Procedures
- Lack of systems
& procedures
- Inappropriate
systems & procedures
- Training
in procedures
- Housekeeping
- Lack of systems
& procedures
Contributing Factors
Investigation Strategy
- Isolate essential
contributory
- Investigation
team
- Evaluates all factors concerned
- Investigation
team
- Isolate essential
contributory factors
- Investigation
team
- Isolates the key factor(s) by asking the following question....
- Investigation
team
Would the accident have happened if this particular factor was not present?
Determine Causes
- Employee actions
- Safe behavior,
at- risk behavior
- Safe behavior,
at- risk behavior
- Environmental
conditions
- Lighting,
heat/ cold, moisture/ humidity, dust, vapors, etc.
- Lighting,
heat/ cold, moisture/ humidity, dust, vapors, etc.
- Equipment condition
- Defective/
operational, guards, leaks, broken parts, etc.
- Defective/
operational, guards, leaks, broken parts, etc.
- Procedures
- Existing
(or not), followed (or not), appropriate (or not)
- 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 wasn’t it fixed?
- If poor lighting,
why not corrected?
- If no training, why not?
- If employee
error, what caused that behavior?
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
- Description
of incident and injuries
- Be objective!
- State facts.
- Assign cause(
s), not blame.
- If referring
to an individuals actions, don’t use names in the recommendation.
- Good:
All employees should…….
- Bad: George should……..
- Good:
All employees should…….
- State facts.
- 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
- Interprets
& draws conclusions
- Investigation
team
Company Accident
Forms
- Must be filled
out completely by the employee and employee’s 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.
- Don’t suffer from TEGO!
What Have You
Learned?
- Final Exercise!
- Review incident
provided
- Determine contributing
factors
- Determine root
causes
- Present report