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Effective Accident Investigation
August 12, 2015Jim BrightRisk Engineering
Zurich Services Corp.
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Session goals & objectives
Understand some effects of worker injuries and losses. Understand that all accidents can be prevented. Instill the above beliefs and attitudes in all employees. Understand the significance of identifying and correcting at-
risk behaviors and conditions. Understand the need and value of conducting thorough and
accurate accident investigations. Understand the role of accountability in the safety process. Reduce accidents and protect employees which reduces
costs and expenses
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Meeting outline
By the end of this session, we want to:
Describe the reasons for conducting accident investigations Identify surface causes and root causes of accidents Learn about identifying (and correcting) unsafe behaviors and
conditions
But first...here’s a few examples of communication difficulties…
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How to fail a test (actual test responses)
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How to fail a test (actual test responses)
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How to fail a test (actual test responses)
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How to fail a test (actual test responses)
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What does an injury cost Hunter Douglas?
Direct Costs• Medical• Compensation
Indirect Costs• Time lost from work by injured• Loss in earning power• Lost time by fellow workers• Loss of efficiency due to disruption of team• Lost time by supervision• Cost of retraining and integration in a new
worker• Damage to tools and equipment• Failure to meet project deadlines• Overhead costs (while work was disrupted)
The proverbial iceberg
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Other costs to consider
• According to Zurich Claims, on average, workers with one to five years of experience represent 55.3% of all reported claims and 40.9% of the net incurred costs.
• Increased WC claim frequency and costs for any employer in 2010 and 2011 will affect experience modifications (Xmod) for a three-year period, 2012-2014.
• Increased Xmods can adversely affect financial objectives. • Due to relatively lower payroll trends in troubled economic times, a lost
time claim will have greater impact on an Xmod than in normal economic times.
• Replacing new hires who have been injured will also result in additional costs.
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Introduction to accident investigation
What is a “near miss” and what is an “accident”?
A NEAR MISS is a failure to meet acceptable standards or processes which creates a hazard where an incident has not occurred, but may or may not result in an accident.
An ACCIDENT is any unplanned and uncontrolled event that results in injury, illness, property damage, activity interruption, or environmental damage.
What do near misses and accidents have in common?
NEAR MISSES and ACCIDENTS are failures of processes, people, equipment, supplies or surroundings to behave or react as expected.
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Introduction to accident investigation
Accidents often result from a dangerous event or sequence of events that we fail to notice and correct until it is too late
Inherent
hazard
Trigger
antecedent
Event or
Sequence of
events
Damage
Injury
Illness
Loss of use, claim, or other
consequences
+ =
Near Miss
Accident
Causes Effects
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Paying attention to the “small stuff”
The Loss Producing Pyramid
300,000 At-Risk Behaviors/Unsafe Conditions
3,000 Near Misses
300 Medical Only
29 Lost Time
1 Fatal
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Introduction to accident investigation
Why investigate? Find the root cause(s) and correct them Prevent similar accidents Protect Hunter Douglas’ interests Fix the problem, but not place blame Improve behavior and hazard identification skills Increase data for trending analysis
When to start – immediately! Witness’s memories fade; people come and go Evidence and clues are lost or moved Information is lost or becomes inaccurate
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A. Gather information1. Care for the injured & secure the scene2. Collect the facts
B. Analyze the facts3. Develop sequence of events4. Determine cause
C. Implement solutions5. Recommendations (lessons learned/corrective actions)6. Write the report
Then measure accident rate to assess effectiveness
Six steps for conducting an accident investigation
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Step 1 – Care for the injured & secure the scene
Your primary goal is to care for the injured and to begin gathering accident information that can give critical clues into the causes associated with the accident:
Provide first aid for injured On scene evaluation Advanced medical care/911 Transport for medical care to designated
clinic for treatment, or to the employee’spredesignated doctor
Control existing hazards Prevent further injuries Get more help if needed Preserve evidence
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Step 2 – Collect the facts
This step requires collection of pertinent facts about the accident to determine the cause of injury:
Who is involved (injured and witnesses) When did it happen An accounting of what happened Where did it happen Obtain employee statement Obtain eyewitness statement(s) Diagrams of the accident and body parts affected
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Step 3 – Develop the sequence of events
In this step, use the information collected to document the events prior to, during, and after the accident
Questions to consider: What project was the injured or affected employee working on before
the accident or near miss happened? Exactly where did it happen? What was the employee doing when the accident or near miss
occurred? The detailed narrative will allow a reader to envision the sequence of
events leading up to the time of the accident that resulted in the employee being injured.
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Step 4 – Determine the Cause(s)
Inadequate training plan
No accountability policy No inspection policy
No discipline procedures
Outdated hazcom programNo orientation process
Inadequate training
Fails to enforceLack of time
Inadequate labeling
CutsBurns
La
ck
of
vis
ion
Strains
No
mis
sio
n s
tate
me
nt
Direct Cause of Injury
Surface Causes
RootCauses
Fact: 96% of accidents are caused by at-risk behaviors4% of accidents caused by unsafe conditions
Source: DuPont Chemicals
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System Elements
INPUTS INTERACTION OUTPUTS• People• Equipment• Material• Environment
Consider your investigation to be a system analysis. All incidents can be analyzed by one or a combination of four elements (or PEME):PeopleEquipmentMaterialEnvironment
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Step 4 – Determine the cause(s)
Direct cause(s) of the accident
This is usually the injury itself, which may take the form of:
Acoustic – hearing loss Chemical burns - corrosive, toxic, flammable, reactive Electrical burns/shock - low/high voltage Kinetic (strains, STF) - energy transferred from impact Mechanical (struck by) - components that move Potential - "stored energy" in objects Radiant - ionizing and non-ionizing radiation Thermal - excessive heat, extreme cold
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Step 4 – Determine the cause(s)
Surface cause(s) or contributing factor(s) of the accident
Specific/unique hazardous conditions and/or unsafe behaviors that may have produced or contributed to the accident, such as:
Unguarded equipment, broken or dull tools, spilled liquid, defective or missing personal protective equipment (PPE)
Horseplay, too much work, failure to train, failure to observe or enforce procedures and rules
If you're pointing at a person, behavior, or thing, then it's probably a contributing factor
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Step 4 – Determine the cause(s)
Root cause(s) of the accident
Program design weaknesses - Failure to effectively develop safety policies, programs, plans, processes, procedures, practices Inadequate or no: training, orientation, job hazard analysis,
coaching/discipline procedures, labeling or hazard communication program
Performance weaknesses - General failure to effectively implement the safety policies, programs, plans, processes, procedures, practices, including training This usually results repeated hazardous conditions and unsafe or
inappropriate performance
If you're pointing at a written plan, policy, procedure, or failures in program implementation, then it's probably a root cause
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Step 5 – Recommend corrective actions and improvements
Recommendations should be specific, constructive, and address the contributing factors and root causes
Recommendations should not include disciplinary action. Focus on redirecting the erroneous behavior – keep it positive!
The hierarchy of controls:
Engineering controls. Eliminate/reduce hazards through equipment redesign, replacement, substitution, removal, etc.
Administrative controls. Eliminate/reduce frequency and duration of exposure to hazards by controlling employee behaviors. Four primary strategies: Develop safe procedures and practices Scheduling Use of personal protective equipment (PPE) Conduct a job hazard analysis
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Step 5 – Recommend corrective actions and improvements
System improvements might include some of the following:
Revising a safety and health plan (IIPP in California) that includes all safety management elements
Improving a safety policy (SOP) so that it clearly establishes responsibility and accountability
Changing a training plan to include demonstration Develop a Job Hazard Analyses (JHA) for key positions Revising purchasing policy to include safety considerations as well as
cost Changing the safety inspection process to include all supervisors and
employees
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Step 6 – Write the report
The teamwork approach lessens the burden and shortens report writing time. Do not gloss over the accident or near miss, a thorough review process may
uncover overlooked hazards and may prevent similar occurrences. Keep an open-mind and be objective When interviewing the employee or witnesses:
Meet in a private room if possible with no distractions Interview witnesses separately Put the person at ease Emphasize the reason for the interview, that is, to determine what happened and why;
not to place blame or punish Let them talk Do not lead, interrupt, prompt, ask leading questions, show your emotions, or jump to
conclusions Do not ask yes/no questions; keep them open-ended Have someone on the team take the extensive notes while others take shorter notes Confirm that you have the facts correct Close on a positive note.
Prepare the Report in an area with few distractions Make sure to follow-up on all recommendations and corrective actions Share best practices with staff.
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Example #1
Slips and falls were occurring outside the company cafeteria due to coffee spills.
Employees were requested in email notifications and sign placed at the exit of the cafeteria to place a lid on all coffee cups.
Slips and falls continued to occur from same apparent cause. Lids were still not placed on coffee cups.
Paper towel dispenser placed outside cafeteria door to wipe up spills.
Slips and falls continued to occur from same apparent cause. Lids were not placed on coffee cups and spills were not being wiped up with towels.
Root cause analysis by interviews determined to be hurried employees.
Corrective action - Lids place at register and handed to employee by cashier to cover coffee cups.
No recurrence of slips and falls from spilled coffee.
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Example #2
Rash of accidents occur at a railroad crossing in Burbank.
Public Utilities Commission report states that the frequency is coincidental.
Critics claim root cause not determined. Intersection configuration is confusing.
Issue remains unresolved.
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Los Angeles Times
April 8, 2003
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Example #2 (Continued)
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Why do accident investigations sometimes fail?
They address only the surface (contributing) causes only; Root causes are often ignored or undetected
The report process or document is too cumbersome or detailed. The report should basically be a “cleaned up” version of all of your hard work and efforts from Step 1 through Step 5
Report is “closed out” and never viewed again. The report should be a “live” document until all actions are complete
When the accident investigator completes the report, they often fail to give it to someone who must do something with it
What else?
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© 2006 Zurich Services Corporation. All rights reserved. The information in this publication and presentation was compiled by Zurich Services Corporation from sources believed to be reliable. Further, all sample policies and procedures herein should serve as a guideline which you can use to create your own policies and procedures. We trust that you will customize these samples to reflect your own operations and believe that these samples may serve as a helpful platform for this endeavor. Any and all information contained herein is not intended to constitute legal advice and accordingly, you should consult with your own attorneys when developing programs and policies. We do not guarantee the accuracy of this information or any results and further assume no liability in connection with this publication and presentation and sample policies and procedures, including any information, methods or safety suggestions contained herein. Moreover, Zurich Services Corporation reminds you that this cannot be assumed to contain every acceptable safety and compliance procedure or that additional procedures might not be appropriate under the circumstances. The subject matter of this publication and presentation is not tied to any specific insurance product nor will adopting these policies and procedures ensure coverage under any insurance policy.
Thank You
Jim Bright805.499.2342 Office818.389.3951 [email protected]
