Accident InvestigationSlide 1 The Basics of Accident Investigation

Accident Investigation Slide 1

The Basics of Accident Investigation


Professional Disclaimer

By no means am I a professional accident investigator…

But I did stay at a Holiday Inn Express last night!

Introduction


Why do we need Accident Investigations?

To prevent future accidents.

To avoid spending money on accidents in the future.

To comply with the law and determine the total cost of an accident

Introduction


Why do we need Accident/Incident Investigations?

Introduction


PRE-ACCIDENT PLANNING

Formal written accident investigation policy

Emergency response plan and training

Accident investigation training

Accident investigation kit

Program Evaluation


Typical Accident Investigation Kit

Barricade Tape Cones Tape Measure Flashlight Evidence Tags Evidence Bags Tweezers Gloves (latex and work) PPE Binoculars

Camera Graph Paper Witness statement forms Notepad and clipboard Analytical technique

forms Copy of the accident

investigation policy

Program Evaluation


Decisions to be made before an Accident Investigation

Determine the level of accident

Decide who will investigate

How much time will be allotted to investigate

Determine if outside resources will be needed

Program Evaluation


WHAT IS ACCIDENT INVESTIGATION?

4 step Process to determine the underlying causes of accidents 1. Analyzing the facts 2. Developing an accident sequence 3. Finding the causes 4. Recommending corrective actions

Causal information used to identify and take preventive action

Introduction


INVESTIGATIVE TECHNIQUES

Preservation of evidence

Types of evidence

Gathering evidence

When to stop collecting evidence

Gathering Evidence


Preservation of Evidence

Cordon off the area Photograph the scene Interview emergency response personnel as

soon as possible Assess the evidence Draw a picture or diagram of the scene

Gathering Evidence


Types of Evidence

Photographic

People

Physical

Paper

Gathering Evidence


Gathering EvidencePhotographic Evidence

Take photos of the “Big Picture”

Include a reference object

Keep a photo log Keep back-up copies in

safe place

Gathering Evidence


INTERVIEWING TIPSPeople Evidence

Choose site carefully. Put the person at ease, explain purpose. Fact-finding process, don’t assess blame. Ask open-ended questions. Take notes. Ask for their opinion. Get contact information.

Gathering Evidence


Gathering EvidencePhysical Evidence

Take universal precautions

Examine equipment, tools, debris, etc…

Note defects

Gathering Evidence


Gathering EvidencePaper Evidence

Policies Procedures Training records Equipment maintenance records Accident records

Gathering Evidence


Charting

Sequence of events: Establishment of

timelines and or charts provides:

The recording of events and conditions in a visual manor.

Validation and verification of facts.

Identification of multiple causes.

Elimination of memorization.

Analyzing Data & Determining Causes


Charting Tips

Fill the chart with information

Make room for your chart

Keep the notes sticky Leave some expansion

room Use computer charts



DETERMINING CAUSES

The root cause is the most fundamental and direct cause of an accident or incident

There may be one or more contributory causes, in addition to the root cause

Accident Investigation is ineffective unless all causes are determined and corrected



CATEGORIES OF ROOT CAUSES

Can be classified as:

Workplace Factors - Largely a function of Management Practices

Employee Factors - Largely a function of Employee Behavior



The Analytical Process

The five whys?

The why staircase



The Five Whys?

Investigator: John, why did the pipe fall on your foot?

John: I dropped it. Investigator: Why did you drop it? John: It slipped out of my hand. Investigator: Why did it slip? John: It was wet. Investigator: Why was it wet? John: It rained earlier today.



The Why Staircase?

“Accident” Why? WHY? WHY? WHY? WHY? “Solution”



Analytical Techniques

Event and Causal Factor Analysis

Root Cause Analysis

Change Analysis

Analytical Trees

Barrier Analysis



CORRECTIVE ACTIONS

Once the cause(s) are determined, corrective actions must be developed and implemented.

Must directly address each cause identified. Consider short term CA’s if permanent CA’s

are not readily available. Reference the “Control Hit List” to make sure

that the “best” corrective actions are used.

Corrective Actions & Reporting


THE CONTROL HIT LIST

1. Eliminate the Hazard

2. Substitute a less hazardous material

3. Use Engineering Controls

4. Use Administrative Controls

5. Personal Protective Equipment (PPE)

6. Training of Employees



Accident Reports

Method of communicating A/I results to others.

Severity and scope of accident dictates which report to use. Accident Logs

Accident Form

Accident Report



Accident Reports

Should include but not limited to: IntroductionMethodologySequence of EventsFacts and AnalysisCausal FactorsCorrective ActionsConclusion and Summary



Review of a Detailed Accident Investigation Report

GROUP DISCUSSION

&

BREAK OUT SESSION


References

Oakley, Jeffrey S. Accident Investigation Techniques. The American Society of Safety Engineers: Des Plaines, Illinois, 2003.

Cianbro The Constructors. Yankee Rowe Decommissioning Project. 1997

Rooney, James J., and Vanden Heuvel, Lee N. Root Cause Analysis For Beginners. Quality Progress, July 2004.

Documents

Accident InvestigationSlide 1 The Basics of Accident Investigation