Accident / IncidentInvestigation

Roxanne Oquendo, MPASafety Training Coordinator

What is an Accident?Accident is defined as:

“Undesired event that may result in harm to people, damage or property or loss to

process.”

“Unplanned event that interrupts the completion of an activity, and that may (or may

not) include injury or property damage.”

Sources: Canadian Centre for Occupational Health & Safety 2008

What is an Incident?

Incident is defined as:

“Usually refers to an unexpected event that did not cause injury or damage this time but had the potential. "Near miss" or "dangerous occurrence" are also terms for an event that

could have caused harm but did not.”

Sources: Canadian Centre for Occupational Health & Safety 2008

Accident Requiring Investigation:

Lost Time Accident or Lost work day Near-miss incidents Medical Treatment Cases First Aid Cases Major property damage

Importance of Investigation in Accident Prevention:

Identify immediate causes of the accident Unsafe Acts Unsafe conditions

Identify basic Causes of the accident Personal factors Job factors Management factors

Identify Losses of Control Lack of procedures Inadequate procedures Inadequate compliance to procedures

Identification of Corrective Actions

Immediate Corrective Actions Prevents recurrence of accident to same employee

Long-term Corrective Actions Prevents same accident from occurring to other employees doing same/similar work

Evaluation of Corrective Actions To determine if corrective actions are effective in preventing similar accidents

Importance of Investigation in Accident Prevention:

The "safety department" wants a report leads to superficial investigations Need to find out who is at fault No attempt made to find real causes Person at fault is usually injured person

Wrong reasons to conduct accident investigations:

1. Investigation Phase

2. Reporting Phase

3. Follow-up Phase

Process in conducting accident investigations:

1. Investigation Phase

Establish relevant accident facts What, When, Where, Why and How (4W & 1H) Interview witnesses Interview the injured Assess the scene of the accident if possible, re-enact accident

Develop solutions to prevent recurrence this is main objective of accident investigation

Process in conducting accident investigations:

2. Reporting Phase Complete the accident report form Follow company procedures Review completed report by appropriate higher

level of management This ensures quality reports by supervisors

Process in conducting accident investigations:

3. Follow-up Phase Assignment of corrective actions Who is going to do what, when Assignments and completion dates must be

monitored /reviewed periodically These are the weakest steps of accident prevention

process

Process in conducting accident investigations:

1. Fear of discipline2. Concern about safety record3. Concern about reputation4. Fear of medical treatment5. Not wanting to lose work time6. Desire to prevent work reputation7. Desire to keep personal record clean8. Avoidance of “red tape”9. Concern about attitude of others10. Poor understanding of importance

Why Employees Fail to Report Accidents?

Time and Place for Accident Investigation What, When, Where, Why and How (4W & 1H)

Interviewing the Employee and WitnessesCorrect and Incorrect Way to InterviewMajor Investigation Errors/Mistakes to AvoidPlanning the Corrective Actions

Conducting the Accident Investigation:

Investigate promptly after the accident With time people will forget details of accident But, do not interview if employee is upset or in

pain

Investigate at the Scene of Accident Helps to re-enact events Gives clear picture of environmental conditions

Conducting the Accident Investigation:

1. Put the person at ease2. Interview on the spot.3. Interview should be private4. Get the individual version5. Ask necessary question at the right time6. Repeat the history once you heard it.7. End each interview on a positive note8. Record critical information quickly9. Keep the pipe line open

Interview Techniques:

Unwillingness to accept management responsibility

Emphasis on a single cause only

Failure to establish root causes

Narrow interpretations of environmental causes

Treating minor injury accidents as minor events

Major Investigation Errors to Avoid:

How to Conduct Accident

Investigation

1. Nature of injury

2. Part of the body

3. Source of injury *- (immediate cause of the injury: energy or hazardous material)

4. Accident type

5. Agency of accident * - (higher or bigger source)

6. Agency of accident part* - (part on contact)

7. Hazardous / Unsafe Condition

8. Unsafe act

Key facts of accident:

1. Amputation, bite, sting

2. Bruise, contusion

3. Burn, hot, cold, chemical, scald

4. Concussion, unconscious

5. Cut, laceration, puncture

6. Exhaustion, heat stroke

1. Nature of Injury:7. Electric shock,

electrocuted

8. Foreign body, sliver, chip, dust

9. Fracture, crush

10. Internal injury, hernia, heart

11. Scrape, scratch, abrasion

12. Sprain, strain

13. Suffocation, drowning

1. Head/Neck - scalp, skull, ears, eyes, face, nose, mouth/teeth, nape

2. Arm/Shoulder - shoulder, upper arm, elbow, forearm, wrist, arm, palm

3. Torso - chest, ribs, back muscles, heart, abdomen, groin, hip, buttock

4. Leg - thigh, knee, shin, calf, ankle, foot, toe5. System - respiratory, circulatory, etc.

2. Parts of the Body:

1. Fall on the same level

2. Fall to below

3. Struck by

4. Struck against

5. Caught on

6. Caught in

7. Caught between

8. Caught with beyond the threshold limit of the body

9. Over-exertion

3. Accident Type:

Types of Accidents

• FALL TO• same level• lower level

• CAUGHT• in• on• between

• CONTACT WITH• chemicals• electricity• heat/cold• radiation

• BODILY REACTION FROM• voluntary motion• involuntary motion

Types of Accidents (continued)

• STRUCK• Against

• stationary or moving object

• protruding object• sharp or jagged

edge• By

• moving or flying object

• falling object

• RUBBED OR ABRADED BY• friction• pressure• vibration

Direct Causes Indirect Causes Basic CausesStruck by/against

Failure to secure

No oversight

Falls Guarding Poor maintenance.

Caught in/between

Improper use Training

Exertion Unsafe position PoliciesContact with…. Environmental StressImpact Defect Engineering

Examples of Accidents Causes

4. Contribution of Safety Controls Engineering Controls - machine guards, safety

controls, isolation of hazardous areas, monitoring devices, etc.

Administrative Controls - procedures, assessments, inspection, records to monitor and ensure safe practices and environments are maintained.

Training Controls - initial new hire safety orientation, job specific safety training and periodic refresher training.

1. Improperly guarded equipment

2. Defective equipment/materials

3. Hazardous arrangement

4. Improper lifting

5. Unsafe dress or apparel

6. Improper ventilation

5. Hazardous/ Unsafe Conditions:

1. Operating equipment without authorization

2. Failure to warn or secure

3. Making safety devices inoperative

4. Using unsafe equipment

5. Improper loading

6. Taking unsafe position

7. Working on moving or dangerous equipment

8. Failure to use PPE

9. Horseplay

6. Unsafe Act:

Accident Investigation Exercise

• Break into teams• Read the scenario handout• Complete the investigation report• Identify the unsafe acts or conditions that

caused the injury

Thank you !!!