Management Safety Policy and Decisions Personal Factors

Environmental factors

Unsafe ActUnsafe

Condition

Unplanned Release of Energyand/or Hazardous Material

AccidentPersonal Injury

Property Damage

Accident Investigation

• An Accident is any unplanned event that results in personal injury

• Failure of equipment, people or surrounding to behave or react as expected

• Accident investigation determines how and why of failure

• Conduct investigations with Prevention in mind - NOT TO PLACE BLAME

Fact- Finding

• Interview witnesses• Inspect the site• take photos,sketch

scene• Record data on maps• get copies of CA-1s• get documents that

include SOPs, charts

Interview Process

• Get statements early • Locate the position of

witnesses on a chart with direction of view

• Explain why you are interviewing

• Focus on direct observation, not hearsay

• Identify qualifications of witnesses

• Give each witness a copy of report,signed by all parties

Problem Solving TechniquesChange Analysis

• Define the problem

• Establish what should have happen

• Identify, locate and describe change

• Specify what was and what was not affected

• List Possible Causes

• Select the most likely causes

Job safety AnalysisProblem Solving

• JSA’s and SOPs are part of an accident prevention program

• HOW ?

• By breaking the job into steps, identifying hazard of each step and prescribing a control for each hazard, you prevent accidents

Reporting the Accident

1. Background Information such as who, when, where

2. Account of Accident a. Sequence of Events b. Extent of damage c.Accident or Injury/Illness type d.Agency or Source

Reporting continued...

3. Discussion ( Analysis of the Accident)

a. Direct causes b. Indirect causes c. Basic causes

Agency or Source Codes

• ANSI Z16.2-1995, source and OSHA

• use these injury type and source codes to code injury and identify the direct causes of the accident

• Examples: Employee slipped on ice,cut hand on rock

Injury code is “Fell on same level”

the Agency or source code is “weather”

the corresponding codes used on the accident forms. See Appendix B

Reporting…

4. Recommendations for immediate and long term action

a. Direct causes- give recommendations b. Indirect causes- give recommendations c. Basic causes

Photographs

• Overall scene

• view from witness’s location

• damaged property

• vehicle report

• view from victim’s location