Accident Investigation

Presented By

 

What is an Accident ?

Accident: Any unplanned event that interrupts

the completion of an activity, and that may (or may not) result in injury or property Damage. Minor accident- requires little or no

treatment for an injury and causes little damage

Serious accident- results in a fatality, permanent disability or large amounts of damage

Accident or Incident?

Incidents are events that occur at all worksites that adversely affect the completion of a task. Accidents are a result of a group of incidents that in combination result in injury or loss of property

Accident Investigation

An investigation that should determine the following: What really happened Why it really happened How it really happenedAnd most importantly, what can we do

to prevent it from occurring in the future !

The ideal investigator

Ideally the investigator should be someone experienced in the area of accident causation, experienced in investigative procedures, familiar with work practices, procedures, environmental effects and personal relationships.

The real life investigator

No previous experience with accident causation, accident investigation, usually a supervisor. Has to fill out all those forms after an accident. Feels that all this paperwork is more painful than what the injured worker is feeling

The Call

Yikes ! We had an accident. What do we do now?

What did you see ?

Don’t panic.Be professional. The calmer you are the more information you will gather. Grab your accident investigation kit and go to the scene.

Investigation Kit

Camera - throw away one time use type. Notebook - Rite in the Rain Accident forms - copy from contractor safety programClipboard - inexpensive typePens (write in the rain) Permanent marker - Sanford Sharpie Fine PointRubber gloves - inexpensive disposable (10-12)Zip lock bags (variety of sizes)Tweezers - inexpensive for picking up evidenceBox knife - inexpensive box knife with snap off bladesMasking tape - 3/4" one roll per kitMetal scribe - usually used to scribe metal, we need it to poke and probe with.Barricade tape "Caution Do Not Enter" 200 foot rollCarrying bag Emergency Action Checklist.

The First 10 Minutes

1st Aid/ 911Some one to meet the ambulance/emergency workers(2 if possible)

Stop work.All Trades All SubsDo not move equipmentSecure Equipment from doing additional damage.

The First 10 MinutesControl The Site

Nobody leaves the siteSet up site security No entry no ExitGather the workers

Locate Subs foremanGet Names and Phone #

Notify the office Request they contact/gather the Crisis Team Members.Contact Experience Person/ABCHow many injured/killed.what hospitals

½ Hour to 2 Hours

Statement from all workers on site.Do not delay this part of the investigation, people talk stories change and memories fade.

½ Hour to 2 HoursTake lots of notes, draw sketches.

The more you write now the more you will remember later.

location of the accident normal work procedure events that preceded the accident

½ Hour to 2 Hours

Pictures, pictures, picturesAll investigators should have access to a disposable camera at a minimum.Digital Secure Chip NEVER ERASETake pictures of everything you feel might be important, don’t forget to take them from different angles

Pictures Pictures Pictures

Pictures Pictures Pictures

Pictures Pictures Pictures

Pictures Pictures Pictures

Pictures Pictures Pictures

Notification

WISHA required notification

Within 8 hours Death 1 in the hospital

Company Notification Determine the contacts

before the accident Insure all supervisors

know the procedure Insure all workers and

supervisors know your media relations policy (Yes you really need one!!)

The Investigation

During the interview process focus on the following What was normal before the accident (normal work

practice) Establishes a baseline for reference What was their exact location during the event What did they notice that was different prior to the

accident When did they notice the change All observations regarding the accident no matter

how small. This includes environmental issues Have each of the witnesses sign their written

statement and their accident report

The Investigation

Clarify the differences between direct observation and hearsay in your notesInsure you directly quote the witnesses in your notes, do not put words in their mouthsDuring the interview process re-interview any witnesses to further clarify the detailsReview any and all pertinent safety documentation including safety meetings training logs and safety violations

Data Analysis

Analyze each of the witness statements How does their story match with the

observed facts. Traumatic witness syndrome The biased witness

Create a logical timeline of events that describe the accident. Place all of the pertinent witness information on the timeline

Create an overall diagram and based on observation and witness information place each individual on the diagram including the direction they were facing

Task ReviewHere the actual work procedure being used at

the time of the accident is explored. Members of the accident investigation team will look for answers to questions such as:

Was a safe work procedure used? Had conditions changed to make the normal

procedure unsafe? Were the appropriate tools and materials available? Were they used? Were safety devices working properly? Was lockout used when necessary?

Equipment & Material Review

To seek out possible causes resulting from the equipment and materials used, you might ask:

Was there an equipment failure? What caused it to fail? Was the machinery poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and

available? Was the raw material substandard in some way? Should personal protective equipment (PPE) have been

used? Was the PPE used?

Environmental Conditions

The physical environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the accident is what is important, not what the "usual" conditions were. For example, you may want to know:

What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts, or fumes

present?

Personnel

The physical and mental condition of those individuals directly involved in the event must be explored. The purpose for investigating the accident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics are considered. Some factors will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done? Had they been adequately trained? Can they physically do the work? What was the status of their health? Were they tired? Were they under stress (work or personal)?

Management

Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation. Answers to any of the preceding types of questions logically lead to further questions such as:

Was safety rules communicated to and understood by all employees?

Were written procedures available? Were they being enforced? Was there adequate supervision? Were workers trained to do the work? Had hazards been previously identified? Had procedures been developed to overcome them? Were unsafe conditions corrected? Was regular maintenance of equipment carried out? Were regular safety inspections carried out?

The Report

If your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings such as: If a limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to "use back of form if necessary." If a checklist of causes is included, possible causes not listed may be overlooked. Headings such as "unsafe condition" will usually elicit a single response even when more than one unsafe condition exists. Differentiating between "primary cause" and "contributing factors" can be misleading. All accident causes are important and warrant consideration for possible corrective action.

The Report

You have kept an open mind to all possibilities and sought out all pertinent facts. There may still be gaps in your tracing of the sequence of events that resulted in the accident. You may need to re-interview to fill these gaps in your knowledge, or you may have to resort to assumptions. Some authorities claim that assumptions have no place in accident investigations. On the other hand, it may better to make assumptions based on what evidence is available, than to leave questions unanswered

The Report

What should be done if the investigation reveals "human error"? A difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough worksite accident investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual. Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation. Furthermore, it will also allow future accidents to happen from similar causes because they have not been addressed.

Summary

Thousands of accidents occur daily throughout the United States. These result from a failure of people, equipment, supplies, or surroundings to behave as expected. A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events.

ANY QUESTIONS