Investigating Accidents

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.
  

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
  
  
  • same level
    
  • lower level
  
  
• Caught
  
  
  • in
    
  • on
    
  • between
  
  
• 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

The Investigation
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?"

• Don’t 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
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.	Subjective Interpretations – based on personal interpretations/ biases. Non- observable – based on events not directly observed. Unreliable – Two or more people don’t agree on what they observed. Non- measurable – a number isn’t used. General – based on non-detailed descriptions.

Investigation Traps

• Put your emotions aside!
  
  
  • 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.
    
    
• 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 wasn’t 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, don’t 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 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