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Accident & Incident Prevention Investigation ... Accident & Incident Prevention & Investigation E ALL accidents & near misses MUST be investigated\爀一攀愀爀氀礀 䄀䰀䰀 愀挀挀椀搀攀渀琀猀

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  • Accident & Incident Prevention

    & Investigation

    E

    Presenter Presentation Notes ALL accidents & near misses MUST be investigated Nearly ALL accidents can be prevented - we should only blame God for about 2% of them, the rest is up to us. Accident Investigation is NOT a method of trying to establish blame - simply a method of identifying the causes in order to prevent a recurrence Accidents, injuries and illnesses cost Australia between 10 and 20 BILLION dollars per year. That is only the reported or “insured” costs. A ratio of 4:1 is regarded as the norm by industry experts - could this mean that there is actually between 40 and 80 billion dollars being spent every year ?

  • Course Objectives & Outcomes

    Understand the need to investigate Know what to investigate Determine the causes of accidents  Identify the methods of investigation Understand the need to be thorough

    and comprehensive  Identify prevention methods  Identify sources of assistance

  • What is an Accident ? Any undesired, unplanned event arising out

    of employment which results in physical injury or damage to property, or the possibility of such injury or damage.

     “Near miss” situations must also be addressed - events which did not result in injury or damage but had the potential to do so.

    Presenter Presentation Notes Incident is an undesired event that could (or does) downgrade the efficiency of the business operation

  • What’s in a name ? Accident  Injury -v- S.B.I.

    Dangerous Occurrence  Significant Incident  “Near-miss” accident  “Near-hit”

    Presenter Presentation Notes Numerous organisations may have a variety of names for various incidents and to that end we must establish known protocols so that we all have an idea of what we are talking about. Refer to legislative requirements for appropriate terminology if there is any question, and wherever a report is the be submitted for legal reasons the correct terminology should be used or alternative descriptions should be provided.

  • 1

    10

    30

    600

    Serious or Disabling Includes disabling & Serious Injuries

    Minor Injuries Any reported injury less than serious

    Property Damage & Accidents All Types

    Accidents with no visible Injury or Damage (Critical Incidents)

    Accident Ratio Study

    Presenter Presentation Notes Source: “Planning Occupational Safety & Health -(3rd Edition) {CCH}

  • Accident Causes

    Unsafe Act  an act by the injured person or

    another person (or both) which caused the accident; and/or

    Unsafe Condition  some environmental or hazardous

    situation which caused the accident independent of the employee(s)

    Presenter Presentation Notes Accidents will have many causes that can be identified by careful and thorough investigation. By identifying the causes we can establish safety solutions (prevention) Some causes may not always be seen by the investigator, therefore a team approach or additional expertise (workers?) may be beneficial

  • Accident Causation Model

     1. Results of the accident - (harm or damage)  2. Incident - Contact (Accident)  3. Immediate causes (symptoms)  4. Basic causes (real problems)

  • Management Safety Policy & Decisions Supervisory Performance

    Personal Factors Job Factors

    Human Factor Substandard

    Practices Substandard Conditions

    ACCIDENT unplanned release of energy

    and/or hazardous material

    Personal injury Property damage Uninsured Costs

    Basic Causes

    Immediate causes

    Incident - Contact

    Accident Results

    CHAIN OF ACCIDENT CAUSATION

  • 1. Results of the Accident (Humane & Economic

    Aspects)  Physical harm (Injury or

    illness)  catastrophic (multiple deaths)  death  disabling, lost time, major  serious  minor  notifiable  compensatable

     Property damage  catastrophic  major  serious  minor

  • 2. Incident - Contact (Accident)

     struck against  struck by  fall to below  fall on same level  caught on  caught in  caught between  over exertion  chemical contact

     Contact with  electricity  plant & equipment  noise or vibration  hazardous substances  radiation  heat & cold  animals or insects  microbiological agents

  • 3. Immediate Causes (Symptoms)

     Standard Practices  operating with authority  use serviceable equipment  use equipment properly  use of PPE where required  correct lifting  no drinking & drugs  no horseplay  secure equipment or

    warnings

     Standard Conditions  effective guards & devices  serviceable tools & equipment  adequate warning systems  good housekeeping  non polluted environment

     noise  hazardous substances

     good illumination & ventilation

     good working, storage & travelling space

    Presenter Presentation Notes Not wise to talk about long lists of unsafe act or unsafe conditions Terms of standard practices and standard conditions

  • 4.Basic Causes (The Real Problem)

     Personal Factors  lack of knowledge or skill  improper motivation  physical or mental conditions  literacy or ability (NESB)

     Job Factors  physical environment  sub-standard equipment  abnormal usage  wear & tear  inadequate standards  design & maintenance  purchasing standards

     Supervisory Performance  inadequate instructions  failure of SOPs  rules not enforced  hazards not corrected  devices not provided

     Management Policy & Decisions  set measurable standards  measure work in progress  evaluate work-v-standards  correct performance if nec

    Presenter Presentation Notes This is the area where most causes can be located and where effective Quality Assurance programs are in place, may of these causes have the potential to be eradicated Organisation policy and procedures should identify and outline specific safety requirements and ensure compliance

  • Why Investigate ?

     Legal Requirement  Establish Causes  Prevent Recurrences Accurate record

    (courts & enquiries)  Statistical data base

    Presenter Presentation Notes In any incident or accident involving death or a serious fire situation, it will be inevitable that a coronial inquest will be conducted. It is therefore crucial that all the facts and supporting documentation, samples and evidence are collated, adequate and complete, ready for presentation

  • What is Accident Investigation ?

     A systematic approach to accident investigation, the identification of causal factors and implementation of corrective actions is essential to a good H&S program and management system. Good procedures:  provide information needed to determine injury rates, identify

    trends or problem areas, permit comparisons and satisfy Workers Compensation requirements;

     identify, without placing blame, the basic causal factors that contributed directly or indirectly to each accident;

     identify deficiencies in management systems;  suggest corrective action alternatives for a given accident;  suggest corrective action alternatives for the management

    system.

    Presenter Presentation Notes In-house accident investigation for minor, or less serious accidents, and near misses should be conducted in an effort to eliminate, or at least reduce any possibility of a recurrence In the case of notifiable injury or accident, the Division of Workplace Health & Safety may wish to get involved and conduct an investigation themselves. An Inspector conducting an investigation may request (or demand) the assistace of WH&S Officers, representatives or any other worker An investigation almost certainly determine inadequacies with the management system, and it is therefore crucial that management support is gained to identify such inadequacies. Again this must NOT be seen as a blame apportioning exercise where workers may blame management, it should be seen as a consultative approach to improve these sytems

  • What, When & How to Investigate

    What to Investigate ?  all accidents & near

    misses  as soon as possible  scene interference  survey of scene  chronology of data  measurements, maps &

    sketches  eyewitnesses  reconstruction ?  statistics & trends  injury types & groups

    Who should Investigate?  Supervisor ?  WH&S Officer?  WH&S Representative?  Team?

     Training & Skills  investigative & recording skills  technical knowledge  interviewing skills  report writing skills

  • The Investigator’s Qualifications

     Technical Knowledge  Objectivity  Analytical approach to

    problems  Familiarity with the job,

    process or operation  Tact in communicating  Intellectual honesty  Inquisitiveness & curiosity

    Presenter Presentation Notes The investigator does not need to be a rocket scientists, simply someone with an understanding of the workplace and an inquisitive, objective nature. A degree of tact is required, especially when consid