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Accident Investigation
WHAT IS AN ACCIDENT?
• What is an accident?o Any unexpected evento Some may even be good
• Does an accident always involve an injury?
• Does an injury always involve an accident?
What Is An Accident?
Accidents
• Accidento Any unplanned event that results in
Personal injury Property damage
Accidents
• Usual causeso Failure of people, equipment, supplies, or
surroundings to behave or react as expected
WHY INVESTIGATE?
• Why investigate?o To PREVENT injuries
• Investigations should not be witch huntso If results show need for discipline, fine But.....o That is not the purpose
INVESTIGATIONS
• Include non injury accidents incidentso Proactiveo Preventative
• Investigating only injurieso Reactive
INJURY PYRAMID
Non-injury Accidents
1st Aid Cases
Recordable
Serious Recordable
Fatality
Incident Investigation Plan
• Establish parameters• Be aware of other requirements
o ADA, EEO, Union, etc.• Establish procedures• Develop forms• Train employees
First Report
The “First Report of Injury” sent to Workers’
Compensation Company is NEITHER an accident report
NOR an investigation.
Incident Report
• Write an incident reporto As soon as possible
• Start with a supervisor’s report based on information provided by employeeso “Employee said......”
Injury Potential
• Investigate based on POTENTIAL FOR INJURY
• The greater the potential, the more thorough the investigation
The Investigation
Avoid a “cold trail”
The Investigation
• Be methodical• Gather as much information as
possibleo Throw out irrelevant information during the
analysis step
The Investigation
• Beware of preconceived conclusions• Beware of “jumping the gun”
o Do not offer solutions before you find the basic cause
The Investigation
• ASK QUESTIONS• When you get an answer, ask “WHY”• Then ask “WHY” again• And AGAIN• And “who?”, “what?”, and ...”why?”
Basic Causes
Management Safety Policies & Decisions Personal Factors Environmental Factors
Indirect Causes Unsafe Act Unsafe Condition
Direct Causes Unplanned Release of Energy
and/or Hazardous Material
Incident
The Investigation
• Investigate the sceneo Take measurementso Take pictureso Evaluate equipmento Be imaginative
The Investigation
• Look foro Guards offo Lack of PPEo Housekeeping issueso Poor work practiceso Faulty equipmento Inadequate trainingo Poorly written procedureso Etc.
The 4 “Ps”
• People • Position• Parts• Paper
Interviews
• Interview employee involved• Interview witnesses• Interview other employees in area• Look for similar incidents
Interviews• Explain the purpose of the investigation
o Accident prevention• Put at ease• Let speak freely• Take notes without distracting • Only use a tape recorder with the
person’s knowledge and consent.• Interview as soon as possible
Analysis Techniques
• Change analysis• Job Safety Analysis (JSA)• Event and Causal Factors Analysis• Multi linear Events Sequencing (MES)• Project Evaluation Tree (PET)• Combination
Report of Investigation
• 1. Background information
• 2. Detailed account of the incident
• 3. Resolution• 4. Corrective actions
RESOLUTION
• Discuss ways of preventing future incidents
• Solicit ideas from employees & others• Be creative• Make recommendations
Corrective Actions
• Corrective actions o Recommendations that are adopted
• Inform and train employees and supervisors
Follow-Up
• Involve supervisors & employees• Are solutions:
o Used?o Effective?
• Solicit feedback
Trend Analysis
• Evaluate for incident, accident and injury trends in order to focus efforts
• Use 300 forms, incident & accident reports, first aid logs, inspection reports, etc.
• Analyze by entity, facility, time, job, etc.
• Do at least a 3 year comparison
Resource
• Ask for help from your workers’ compensation carrier
Sandra A. Mihalik, WSO-CSTSafety & Health Specialist
Montana Safety & Health BureauPhone: 406.444.6418
E-mail: [email protected]