Accident /Incident InvestigationPaul Thornton

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Key learning points

KLP to first slide

Why investigate accidents and incidents?

Investigating accidents and incidents

Course raises awareness

The training yesterday has raised your awareness of the importance of identifying and controlling risks before harm

occurs

Things may go wrong

However, sometimes things may go wrong. You need to know what to do on these occasions, and how to learn from

them

DEF: Incident

An incident could be described as an undesired event that doesn’t result in harm, but has the potential to do so

DEF: Incident

An undesired event with this result may also be described as a near miss

DEF: Accident

An accident is an undesired event that does result in harm and/or property damage

Prevent from happening

Accidents and incidents should be investigated to identify the cause so that it can be prevented from happening again

Reasons to investigate

Other reasons to investigate accidents and incidents include:

• collecting information for insurance purposes

• determining the cost of an accident

• collecting the required information for notifying authorities

Reasons to investigate

Key benefits of investigation:

• developing useful skills andknowledge that can beapplied throughoutthe organisation

• making a safer work environment

• improving worker morale

• preventing further business losses from disruption, down-time and lost business

Incidents need investigations

Remember: incidents that don’t result in harm or loss still need to be reported and investigated.

- might happen again

Remember: incidents that don’t result in harm or loss still need to be reported and investigated.

An incident might result in more serious consequences if it were to happen again

How do accidents and incidents happen?

ACCIDENT intro

- 4:30 - head for fire exit

- Speedy forklift

- What was the cause?

Finding the Cause of Accidents

Accident investigation allows us to find out the cause of an

accident or incident.

However, accidents and incidents are rarely caused by a single factor – there are usually several contributory factors.

Also, these factors will include obvious and immediate causes and less obvious underlying causes.

Immediate causes

Are unsafe actions or lack of action (for example, operating equipment with missing guards and bypassing interlocks,

using the wrong personal protective equipment) and unsafe conditions (for example, damaged tools and equipment

and high noise and low lighting levels).

Finding the Cause of Accidents

Underlying Causes

Are factors that allow the unsafe actions and conditions to happen.

The majority of these are related to the way the organisation manages health and safety and how people perceive risk

Finding the Cause of Accidents

Root Causes

A root cause is a factor that may cause conditions that could result in an undesirable event. If the problem were corrected, it’d prevent the undesirable event from happening.

In other words, a root cause is an event from which all other causes spring.

Finding the Cause of Accidents

- struck = injury

Finding the Root Cause(s)

Work in your groups to identify the Immediate, Underlying and Root Causes of this incident

ACCIDENT intro

- 4:30 - head for fire exit

- Speedy forklift

- What was the cause?

- tipped + skidded

- skid = oil + brake

- oil = leak

- leak = no supervision

- brake = speed + step

- speed = rushing + work pressure

- governor

- governor = no supervision

- emergence = poor c&p

- causal tree

- Immediate, underlying, root

- management

Remember: immediate

Remember: if you only investigate as far as the immediate causes, there’s a much higher likelihood that it will happen

again

---== KLP3: Investigation? ==---

How do you carry out

an investigation?

Aftermath of accident

1. Ensure wellbeing

1. Ensure the wellbeing of the injured person

2. Preserve scene

2. Preserve the scene

3. Report

3. Report the accident (or incident)

- to whom

‣ senior management‣ enforcing authority‣ injured person’s family‣ owner of assets‣ insurance company‣ safety/employee

representatives‣ health and safety and

human resources departments

3. Report the accident (or incident)

- report form

3. Report the accident (or incident)

4. Assemble team

4. Assemble the investigation team

- someone familiar4. Assemble the investigation team

• someone familiar with the work location

- supervisor4. Assemble the investigation team

• supervisor or manager from work location

- senior mgmt

4. Assemble the investigation team

• senior manager with authority or influence

- h&s expert4. Assemble the investigation team• health and safety expert

- employee rep4. Assemble the investigation team

• employee representative

- involved in event4. Assemble the investigation team

• person involved in event (if possible)

- technical expert4. Assemble the investigation team• technical expert (if necessary)

- Size of team

The size of the team is determined by the size of the organisation

- Size of investigation

The level of investigation is determined by the likelihood of recurrence and the potential worst consequences of the

undesired event

5. Investigate

5. Investigate using a structured approach

- Gather5. Investigate using a structured approach• Gather information

- Gather points5. Investigate using a structured approach• Gather information

• physical• human• documentary

- Analyse5. Investigate using a structured approach

• Analyse findings

- Risk control5. Investigate using a structured approach• Review current risk controls

- Action plan5. Investigate using a structured approach

• Create an action plan

- Investigation report5. Investigate using a structured approach

6. Handle external6. Handle external relations

- enforcement6. Handle external relations• Enforcement authorities

- media6. Handle external relations• Media

- locals6. Handle external relations• Local residents and businesses

Getting it right

Getting it right:

• Investigation is about avoiding it happening again, not attributing blame

• Having plans in place before an accident will help for an effective investigation

• Sharing the findings is as important as ensuring the quality of the investigation

KLP Summary

‣ Why investigate accidents and incidents?‣ How do accidents and incidents happen?‣ How do you carry out an

investigation?

Key learning points:

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Key learning points:

• Why investigate accidents and incidents?• How do accidents and incidents happen?• How do you carry out an

investigation?

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