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
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