ACCIDENT /INCIDENT INVESTIGATION AND REPORTING

OverviewPurpose of Investigation

Managing the Accident Scene

Steps in Conducting Investigation

Investigations are conducted to: Prevent recurrenceComply with policies and regulatory requirementsMaintain employee awareness

ACCIDENTAn undesired event that results in harm to people, damage to property, or loss to process

ILO Accident Report Accidents - 250 M/year or 685 T/day or 475/minute or 8/second Working children - 12 M (recorded), 12,000 are fatal Working Adults - 3,000/day = 2/min.

Types of Accident1. Personal injury or illness2. Property damage3. Combination of items 1 & 24. Near-miss (actually an incident)

INCIDENTAn undesired event which, under slightly different circumstances, could have resulted in harm to people, damage to property, or loss to process

Accidents are the result of: :Unsafe ActsUnsafe Conditions

UNSAFE ACTSBehaviors which could permit the occurrence of an accident or incidentDeviation from standard procedures or practices

UNSAFE CONDITIONSCircumstances which could permit the occurrence of an accident or incident Deviation from standard conditions (equipment, materials, or environment)

Unless the unsafe acts/conditions are:

Prevention is the reason for conducting an Accident Investigation

Identified andEliminated or controlled similar mishaps will occur

Accident Investigations are usually considered a Supervisors responsibility

Advantages of Supervisors over other investigators:More familiar with the people involvedBetter understanding of the operationsPersonal interest in investigations

Team EffortAll employees should understand :What to reportHow to report

What to Report:LTINon-LTINear MissesProperty DamageChemical SpillFire or Explosion

Whom to Report to:

MedicalSafetyEnvironmental ControlManagement

Managing the Accident SceneTwo Priorities:Care & treatment of the injuredElimination or control of remaining hazards

Care & Treatment of Injured

Training in First AidDrills under normal and abnormal conditionsLiaison with hospitalsSupervisors can increase their ability to respond to Medical Emergencies by:

Controlling Remaining HazardsNotify necessary personnelProvide PPE to potentially exposedRefer to MSDSIf a hazardous environment or toxic materials exist:

Isolate the siteTo protect people from further injuryTo preserve evidence and valuable clues

Successful investigation is done ...ImmediatelyCompletelyThoroughly

Investigate immediately, because:Operations are disruptedMemories fadeEmployees are at risk

Conducting the InvestigationGather informationAnalyze the facts Make recommendations

ACCIDENT INVESTIGATIONGuidelines:1. Investigate immediately2. Ensure immediate treatment3. Secure the area4. Record details of event (photo, sketch, etc.)5. Collect physical evidence6. Review other sources (victims record, friends, etc.)7. Interview witnesses (5Ws + 1H)8. Write causal factors (man, machine, material, method)9. Make recommendations (effective/reliable results)

Gathering Information

personnel involvedproperty damageenvironmental harmPreliminary Facts:

Accident Investigation EquipmentReport formNotebook or pad of paperTape recorderCamera (instant or digital)Measuring equipment

Sources of InformationWitnessesPhysical evidence at the sceneExisting records

WitnessesVictim and onlookersThose who heard what happenedSaw area prior to incident

Interviewing Witnesses:1. Reassure the witness2. Let the witness tell the story3. Begin with open-ended questions4. Dont ask leading questions

Interviewing Witnesses5. Summarize6. Ask for recommendations7. Get written statements8. Close on a positive note

ACCIDENT INVESTIGATIONQuestions for reporting: WHO- was injured?- saw the accident?- was working with the injured?- had instructed/assigned the job to the injured?- else was involved?

ACCIDENT INVESTIGATIONQuestions for reporting: WHAT- is the injury?- is the damage or loss?- was the injured doing?- had the injured been instructed to do?- tools/equipment/machinery were being used?-- training had been given?- is the state of health of the injured?- safety rules were violated?- safety system and procedures were there?

ACCIDENT INVESTIGATIONQuestions for reporting: WHEN- did the accident occur?- did the injured start the job?- was the explanation of hazard given?- did the supervisor last see the injured?- did the persons involved last have food & rest?

ACCIDENT INVESTIGATIONQuestions for reporting: WHY- did the injury occur?- did the communication fail?- was the training not given?- was PPE not provided?- was PPE not used?- was there no safety instruction given?- was the supervisor not there at the time?

ACCIDENT INVESTIGATIONQuestions for reporting: WHERE- did the accident occur?- did the damage occur?- was the supervisor at that time?- was the witnesses at that time?

ACCIDENT INVESTIGATIONQuestions for reporting: HOW- did the injury occur?- could the accident have been avoided?- could have been the injury avoided?- could the supervisor have prevented the accident?

SketchesTo record important details at the accident site for later study

Electrocution victimComfort Room

Include everything that could be important:Floor plan from overhead viewLocation of involved man,machine, toolSize and location of transient evidences (spills, dust, footprints, skid marks)

AHUXX

Photographsdetailcolor differencescomplex shapes difficult to recall

PhotographsGeneral areaDetailed shotsShow scale on small objectsBetter to take too many than too few

MaterialsToolsMachinesEXAMININGExamining Physical Evidence

Machines & ToolsPhysical condition Position of switches/leversReading of gaugesSafeguardsWarning devices

MaterialMisuseAbuseDisuseImproper handlingDamagePosition and condition can indicate

Material - ChemicalIf chemicals are involved:correct item usedcorrect concentrationexpiredcontaminatedMSDS availability (Materials Safety Data Sheet)

If items have to be removed from the scene for detailed examination:Log and labelSecure storage & transportAvoid contaminationGuard against tampering and lossAppropriate warnings

Existing RecordsEmployee recordsEquipment recordsJob or Task recordsPrevious Accident Investigation reports

Analyzing the FactsCause Analysis (root)Change analysis

Immediate and Basic Causes

Direct CausesBasic (root)Causes

Direct Causes

caught in, between, or under struck against or struck by fall from or fall on overexertion or stress

Basic (Root) Causes inadequate maintenance of equipment inadequate codes and standards insufficient employee safety training safe work practices inadequately followed faulty design of work area supervisors not performing duties

Change AnalysisCompares how a job was actually performed with the way it should have been performed

Recommending Corrective ActionsSpecificMeasurableAttainableRealisticTime-bound

Report forms require four basic types of informationGeneral informationA SummaryAn AnalysisRecommendations

Reports should beClearDetailedNeat Legible

Management ApproachTrainingInspectionsHazard analysisSafety Meetings

Not just for incidents involving serious injury, its for ANY occurrence that has the POTENTIAL of causing harmAccident Investigation...

ACCIDENT INVESTIGATION (General Process Flow)Secure the areaDocument the facts: hard evidence, witnessEnsure immediate medical treatmentGather facts about the accident: witnessesIdentify the root cause (causal factors)Corrective actionFollow-up

Quote of the day:

It is better to be careful 100 times than to get killed once Mark Twain

The EndThank You and Good Morning