Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may...

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Transcript of Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may...

Page 1: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 2: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Accident Investigation

Page 3: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

WHAT IS AN ACCIDENT?

• What is an accident?o Any unexpected evento Some may even be good

• Does an accident always involve an injury?

• Does an injury always involve an accident?

Page 4: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

What Is An Accident?

Page 5: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Accidents

• Accidento Any unplanned event that results in

Personal injury Property damage

Page 6: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 7: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Accidents

• Usual causeso Failure of people, equipment, supplies, or

surroundings to behave or react as expected

Page 8: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 9: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

WHY INVESTIGATE?

• Why investigate?o To PREVENT injuries

• Investigations should not be witch huntso If results show need for discipline, fine But.....o That is not the purpose

Page 10: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

INVESTIGATIONS

• Include non injury accidents incidentso Proactiveo Preventative

• Investigating only injurieso Reactive

Page 11: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

INJURY PYRAMID

Non-injury Accidents

1st Aid Cases

Recordable

Serious Recordable

Fatality

Page 12: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Incident Investigation Plan

• Establish parameters• Be aware of other requirements

o ADA, EEO, Union, etc.• Establish procedures• Develop forms• Train employees

Page 13: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

First Report

The “First Report of Injury” sent to Workers’

Compensation Company is NEITHER an accident report

NOR an investigation.

Page 14: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Incident Report

• Write an incident reporto As soon as possible

• Start with a supervisor’s report based on information provided by employeeso “Employee said......”

Page 15: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Injury Potential

• Investigate based on POTENTIAL FOR INJURY

• The greater the potential, the more thorough the investigation

Page 16: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 17: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

Avoid a “cold trail”

Page 18: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

• Be methodical• Gather as much information as

possibleo Throw out irrelevant information during the

analysis step

Page 19: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

• Beware of preconceived conclusions• Beware of “jumping the gun”

o Do not offer solutions before you find the basic cause

Page 20: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

• ASK QUESTIONS• When you get an answer, ask “WHY”• Then ask “WHY” again• And AGAIN• And “who?”, “what?”, and ...”why?”

Page 21: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Basic Causes

Management Safety Policies & Decisions Personal Factors Environmental Factors

Indirect Causes Unsafe Act Unsafe Condition

Direct Causes Unplanned Release of Energy

and/or Hazardous Material

Incident

Page 22: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

• Investigate the sceneo Take measurementso Take pictureso Evaluate equipmento Be imaginative

Page 23: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The Investigation

• Look foro Guards offo Lack of PPEo Housekeeping issueso Poor work practiceso Faulty equipmento Inadequate trainingo Poorly written procedureso Etc.

Page 24: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 25: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 26: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

The 4 “Ps”

• People • Position• Parts• Paper

Page 27: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Interviews

• Interview employee involved• Interview witnesses• Interview other employees in area• Look for similar incidents

Page 28: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Interviews• Explain the purpose of the investigation

o Accident prevention• Put at ease• Let speak freely• Take notes without distracting • Only use a tape recorder with the

person’s knowledge and consent.• Interview as soon as possible

Page 29: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Analysis Techniques

• Change analysis• Job Safety Analysis (JSA)• Event and Causal Factors Analysis• Multi linear Events Sequencing (MES)• Project Evaluation Tree (PET)• Combination

Page 30: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Report of Investigation

• 1. Background information

• 2. Detailed account of the incident

• 3. Resolution• 4. Corrective actions

Page 31: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

RESOLUTION

• Discuss ways of preventing future incidents

• Solicit ideas from employees & others• Be creative• Make recommendations

Page 32: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Corrective Actions

• Corrective actions o Recommendations that are adopted

• Inform and train employees and supervisors

Page 33: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Follow-Up

• Involve supervisors & employees• Are solutions:

o Used?o Effective?

• Solicit feedback

Page 34: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Trend Analysis

• Evaluate for incident, accident and injury trends in order to focus efforts

• Use 300 forms, incident & accident reports, first aid logs, inspection reports, etc.

• Analyze by entity, facility, time, job, etc.

• Do at least a 3 year comparison

Page 35: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Resource

• Ask for help from your workers’ compensation carrier

Page 36: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?
Page 37: Accident Investigation WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury?

Sandra A. Mihalik, WSO-CSTSafety & Health Specialist

Montana Safety & Health BureauPhone: 406.444.6418

E-mail: [email protected]