Accident Investigation

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Learning from our Mistakes

Accident Investigation

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• InstructorInstructor• ScheduleSchedule• ParticipantsParticipants• MaterialsMaterials• ObjectivesObjectives

IncidentIncidentInvestigationInvestigation

Course Introduction

Accident Investigation

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• Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up

• Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up

Accident Investigation

Course Objectives

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• To determine root causes and preventTo determine root causes and prevent recurrence of similar accidents recurrence of similar accidents• To demonstrate to employees thatTo demonstrate to employees that management cares management cares

• To determine root causes and preventTo determine root causes and prevent recurrence of similar accidents recurrence of similar accidents• To demonstrate to employees thatTo demonstrate to employees that management cares management cares

Why Investigate?

Accident Investigation

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EverythingEverything EverythingEverythingSeriousSerious InjuriesInjuries

Minor InjuriesMinor Injuries

Non-injury IncidentsNon-injury Incidents

ChancesChances

112929

300300

350,000350,000

Accident Investigation

What to Investigate?

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Why don’t employees report everything?Why don’t employees report everything?

I saidI saidreportreport

EVERYTHINGEVERYTHING!!!!

Accident Investigation

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Resources to find out include:Resources to find out include:• PPeopleeople• AAccident Sceneccident Scene• RRecordsecords

““PAR for the course”PAR for the course”

What Happened?

Accident Investigation

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Acc

ident

Acc

ident

Imm

edia

te C

ause

sIm

media

te C

ause

s

Basi

c C

ause

sB

asi

c C

ause

s

Safe

ty S

yst

em

Safe

ty S

yst

em

Accident Sequence

Accident Investigation

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The Work SystemThe Work System The EmployeeThe Employee

SystemSystemFailures

Failures

BasicBasic

CausesCauses

ImmediateImmediateCausesCauses

Causes

Accident Investigation

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• Case #1 - How do you spell relief?Case #1 - How do you spell relief?• Case #2 – Back to the GrindCase #2 – Back to the Grind

Danger - HighDanger - HighPressurePressure

Workshop

Accident Investigation

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The ReportThe Report The RepairThe Repair The ReviewThe Review

Follow-Up

Accident Investigation

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•Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up

Summary

Accident Investigation

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• We investigate to show we care and prevent recurrenceWe investigate to show we care and prevent recurrence• We investigate everything a little to see where we needWe investigate everything a little to see where we need to investigate a lot to investigate a lot• We use people, the accident scene and records (PAR) toWe use people, the accident scene and records (PAR) to find out what happened find out what happened• We use the Accident Analysis Flow Chart and ask “Why” We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’s to help find out why the accident occurred and realize it’s almost always rooted in the management system almost always rooted in the management system• We report, repair and review to make sure that the actionsWe report, repair and review to make sure that the actions necessary to prevent recurrence are completed necessary to prevent recurrence are completed

Summary

Accident Investigation

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ClosingClosing

Accident Investigation