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Incident/Accident Analysis 1 Introduction to effective Incident/Accident Analysis

Incident/Accident Analysis 1 Introduction to effective Incident/Accident Analysis

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Incident/Accident Analysis 1

Introduction to effective

Incident/Accident Analysis

Incident/Accident Analysis 2

After attending this workshop you should be able to:

1. Describe the primary reasons for conducting an accident investigation.

2. Discuss employer responsibilities related to workplace accident investigations.

3. Conduct the six step accident investigation procedure

Objectives

© 2003 Steven J. Geigle. All rights reserved.This material, or any other material used to inform employers of compliance requirements of OSHA standards through simplification of the regulations should not be considered a substitute for any provisions of the Occupational Safety and Health Act of 1970 or for any standards issued by OSHA. The information in this publication is intended for training purposes only.

Incident/Accident Analysis 3

What’s the definition of an accident?

Identify two key conditions that must be present for any accident to occur.

A Hazard and Exposure

Incidents and accidents

Incident/Accident Analysis 4

What’s the difference between accident investigation and Analysis?

The basics

To gain the greatest benefit, why does the employer conduct accident analysis?

First - determine what happened to see safety management system weaknesses exist.

What's the purpose of an OSHA investigation?

First - determine what happened to see if the employer violated safety rules.

Incident/Accident Analysis 5

What are the basic steps in doing the accident investigation and report?

Step 1 - Secure the accident scene

Step 2 - Collect facts about what happened

Step 3 - Determine the sequence of events

Step 4 - Determine the causes

Step 5 - Recommend improvements

Step 6 - Write the report

The process

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Step 1: Secure the Scene

When is it appropriate to begin the investigation?

What are effective methods to secure an accident scene?

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List methods to document the scene and collect data about what happened.

What documents will you be interested in reviewing?

Why?

Step 2: Collect facts about what happened

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When is it best to interview? Why?

Who should we interview? Why?

Where should we conduct the interview?

Interviewing

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What are are effective interviewing techniques?

Always say this.. Why?

Always do this... Why?

Never say this… Why?

Never do this... Why?

Cooperate, don’t intimidate

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Team Exercise: Cooperation is the Key

Instructions. Your instructor has had an accident. Your team and the instructor are located at the scene of the accident (classroom) and your job now is to ask initial and follow-up questions to gather information about the accident.

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Step 3: Develop the sequence of events

Each event in the unplanned accident process describes one:

Actor - The, object, person that is initiating action.

Action- The thing being done, behavior

“Dale slipped on a banana.”

“As Dale lay on the floor, a brick fell on his head .”

“Larry discovered Dale unconscious on the floor and immediately began initial first aid procedures.”

Incident/Accident Analysis 12

Team Exercise: Develop the sequence

Instructions. Use the information in the interview summaries below to construct a sequence of events listing the events prior to, during and after the accident they describe.

1. Determine the “injury event.”

2. List the events that led up to the injury.

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Step 4: Determine the causes

W. H. Heinrich's domino Theory

"The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the accident itself."

Dan Petersen's Multiple Cause Theory

"Behind every accident there are many contributing factors, causes, and subcauses. These factors combine in a random fashion causing accidents."

What may be the cause(s) of the accident according to the multiple causation theory?

What might be the solutions to prevent the accident from recurring?

Incident/Accident Analysis 14

Inadequate training plan

No accountability policy No inspection policy

No discipline procedures

No orientation process

Inadequate training

Fails to enforceLack of time

No recognition

CutsBurns

La

ck o

f v

isio

n

Strains

No

mis

sio

n s

ta

te

me

nt

17

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The causes of Injury, Illness and Accidents

1. Direct Cause of Injury

2. Surface Causes of the Accident

3. Root Causes of the Accident

Steps in root cause analysis

1. Injury cause analysis

2. Surface Cause analysis

3. Root Causes analysis- Accident Causes

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Team Exercise: “Getting to the roots by asking why, why, why, why”

1. Analyze the injury event to identify and describe the direct cause of injury.

a. Describe the injury and it’s cause.

b. Identify the accident type.

Incident/Accident Analysis 17

Injury -1 -2 -3 -4 -5 -6 -7 -8

Blade cuts Bob

Bob saws wood

Ralph removes guard

Replace blade

Ralph doesn’t replace guard

Ralph directed to stop and fix chipper

Bob behind schedule

Bob decides to ignore missing guard

Corrective MX, blade is broken

High priority emergency repair

Wood shipment arrives late

Others use the unguarded saw

The guard slows workNo one is disciplined

Doesn’t want to make boss mad

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Exercise: Digging up the roots

1. Enter the direct cause of injury within the circle below.

2. List one hazardous condition and unsafe behavior from the sequence of events your group developed.

3. Determine contributing surface causes for the hazardous condition and unsafe behavior.

4. Determine implementation and design root causes for contributing surface causes.

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Use control strategies to make corrective actions

• Engineering Controls. Eliminate/reduce hazards through equipment redesign, replacement, substitution, etc.

• Management Controls. Eliminate/reduce exposure to hazards by controlling employee behaviors.

• Interim Measures. These include strategies that are used as a temporary fix while permanent controls are being developed.

Step 5: Recommend corrective actions and improvements

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Team Exercise: Recommending Corrective actions

Purpose: In this exercise you’ll develop and recommend immediate actions to correct the surface causes of an accident.

Instructions. Using the control strategies as a guide, determine corrective actions that will eliminate or reduce one of the hazardous conditions or unsafe behaviors identified in the previous exercise. Write your recommendation below.

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Recommend system improvements

Make improvements to policies, programs, plans, processes, and procedures within one or more of the following elements of the safety management system.

1. Management commitment

2. Accountability

3. Employee involvement

4. Hazard identification and control

5. Incident and accident analysis

6. Education and training

7. System evaluation

Incident/Accident Analysis 22

Making system improvements might include some of the following:

• Including "safety" in a mission statement.

• Improving safety policy so that it clearly establishes responsibility and accountability.

• Changing a training plan to include using checklists.

• Revising purchasing policy to include safety considerations as well as cost.

• Changing the safety inspection process to include all supervisors and employees.

Incident/Accident Analysis 23

Team Exercise: ”Fix the system...not the blame"

Purpose: In this exercise you’ll develop and recommend one improvement to make sure the case study accident does not recur.

Instructions. Develop and write a recommendation to improve one or more policies, plans, programs, processes, procedures, and practices identified as design weaknesses.

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SECTION I. BACKGROUND

SECTION II. DESCRIPTION OF ACCIDENT

SECTION III. FINDINGS

SECTION IV. RECOMMENDATIONS

SECTION V: SUMMARY

SECTION VI: FOLLOW-UP: ACTIONS

SECTION VII: COMMENTS/ATTACHMENTS:

Step 6: Write the report

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Take Corrective Action

Conduct follow-up evaluation

Conduct annual review of reports

The report is an open document until all actions are complete!

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That's it!

Be safe