Participant Workbook(3)(1)

Introduction to Accident Investigation

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This material is for training purposes only.

Welcome

Course Overview

Part One

• Accident investigation definitions

• Characteristics of an effective program

Part Two: The six-step process

• Step 1: Preserving and documenting the accident scene

• Step 2: Collecting the facts through interviews

• Step 3: Developing sequence

• Step 4: Determining causes

Part Three

• Step 5: Developing effective recommendations

• Tools and techniques to measure costs/benefits

• Step 6: Writing the report

Form Groups

Discuss and report:

•Problems you have seen when thorough

accident investigation techniques are not

practiced, or

•Positive results when thorough accident

investigations are conducted.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Introductions

Elect a group leader

Select a spokesperson

and recorder – or

alternate responsibilities


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After attending this workshop, the participants will be able to:

1. Identify basic accident investigation concepts and describe the characteristics

of an effective accident investigation program.

2. Describe the six-step process for conducting accident investigations.

3. Conduct an accident investigation following the six-step procedure.

Objectives

What is an accident?

_________________________________________________________

_________________________________________________________

________________________________________________________

What 2 key conditions must exist before an accident occurs?

_________________________________________________________

What causes most accidents?

According to the State of Oregon, • Hazardous conditions account for __% of all workplace accidents.

• Unsafe/inappropriate behaviors account for __% of all workplace

accidents.

• Uncontrollable acts account for ___% of all workplace accidents

• Management is able to control factors that produce ____ % of all

workplace accidents.

What is the difference between accident investigation and

accident analysis?

_________________________________________________

_________________________________________________

_________________________________________________________

Does your organization conduct accident investigations for

the same reason as OSHA?

_____________________________________________

The basics


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- Iceberg

1.Workers’ compensation premiums

2. Miscellaneous medical expenses. Medical expenses

include doctor fees, hospital charges, the cost of medicines,

future medical costs, and ambulance, helicopter, and other

emergency medical services.

Direct -

Insured Costs

Indirect - Uninsured, Hidden Costs - Out of Pocket

Examples:

1. Lost time by fellow employees/supervisor.

2. Investigation of accident.

3. Schedule delays.

4. Legal fees.

5. Training costs for new/replacement workers.

6. Damage to tools and equipment.

7. Lower morale.

8. Increased absenteeism.

9. Poorer customer relations.

10. Others?

Unseen

costs can

sink the

ship!

Indirect costs are those costs not covered

by insurance. They aren’t as obvious as

direct costs, but can add up.

What do accidents cost your company?

Average direct and indirect accident costs

Non-Lost-time injury: $7,000 Lost- time injury: $28,000 Fatality: $980,000 Using National Safety Council average costs for 2000; includes both direct and indirect costs; excludes property damage.

Direct to Indirect Accident Cost Ratios

Studies show that the ratio of indirect to direct costs can vary widely, from a high of 20:1 to a low of 1:1. Source: Business Roundtable, 1982.


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Are accidents always unplanned?

____________________________________________________________

____________________________________________________________

____________________________________________________________

What’s the difference between an incident and an accident?

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

The basics

An effective incident/accident analysis program includes:

1. Clearly stated and easy to follow written procedures.

2. Clearly assigned responsibility for conducting accident investigations.

3. All accident investigators will be formally trained on accident investigation

techniques and procedures.

4. Separation of the accident investigation from any potential disciplinary

procedures resulting from the accident. The purpose of the accident

investigation is to get at the facts, not find fault.

5. A written report, addressing the surface causes and root causes, with

recommendations to correct hazardous conditions and work practices, and

those underlying system weaknesses that "caused" them into existence.

6. Follow-up procedures to make sure short and long-term corrective actions

are completed.

7. An annual review of accident reports to make sure root causes are being

addressed and corrected, so that information about the types of accidents,

locations, trends, etc., can be gathered.

Characteristics of an Effective Accident Investigation Program


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The basics

Who should investigate?

____________________________________________________________

____________________________________________________________

____________________________________________________________

Group Exercise - Evaluate a Sample Program

Instructions:

Review the following sample accident investigation program. Edit the program as

you think it should be written.

Does it meet the criteria you said was important?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

What should be added/changed?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________


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“Fix The System” Incident/Accident Analysis Plan

1.0 General Policy

____________________ considers employees to be our most valued asset and as such we will ensure that all

incident and accidents are analyzed to correct the hazardous conditions, unsafe practices, and improve related

system weaknesses that produced them. This incident/accident analysis plan has been developed to ensure our

policy is effectively implemented.

____________________ will ensure this plan is communicated, maintained and updated as appropriate.

2.0 Incident/Accident Reporting

2.1 Policy. All employees will report immediately to their supervisor, any unusual or out of the ordinary

condition or behavior at any level of the organization that has or could cause an injury or illness of any kind.

Supervisors will recognize employees immediately when an employee reports an injury or a hazard that could

cause serious physical harm or fatality, or could result in production downtime.

2.2 _____________________ will ensure effective reporting procedures are developed so that we can quickly

eliminate or reduce hazardous conditions, unsafe practices, and system weaknesses.

3.0 Preplanning.

Effective incident/accident analysis starts before the event occurs by establishing a well thought-out

incident/accident analysis process. Preplanning is crucial to ensure accurate information is obtained before it is lost

over time following the incident/accident as a result of cleanup efforts or possible blurring of people’s

recollections.

4.0 Incident/Accident Analysis.

4.1 All supervisors are assigned the responsibility for analyzing incidents and accidents in their departments. All

supervisors will be familiar with this plan and properly trained in analysis procedures.

4.2 Each department supervisor will immediately analyze all incidents that might have resulted in serious injury or

fatality. Supervisors will analyze incidents that might have resulted in minor injury or property damage within 4

hours from notification.

4.3 The supervisor will complete and submit a written incident/minor injury report through management levels to

the plant superintendent. If within the capability/authority of the supervisor, corrective actions will begin

immediately to eliminate or reduce the hazardous condition or unsafe work practice that might result in injury or

illness.


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4.4 In cases of an incident/accident such as a fire, release, or explosion emergency, the supervisor will:

1. Secure or barricade the scene;

2. Immediately collect transient information;

3. Interview personnel.

5.0 Incident/Accident Analysis Team 5.1 Incident/Accident Analysis Team Makeup

If the supervisor determines that additional assistance is needed for investigation, a team will be compiled and may

include:

1. A third-line or higher supervisor from the section where the event occurred;

2. Personnel from an area not involved in the incident;

3. An engineering and/or maintenance supervisor;

4. The safety supervisor;

5. A first-line supervisor from the affected area;

6. Occupational health/environmental personnel;

7. Appropriate wage personnel (i.e., operators, mechanics, technicians); and,

8. Research and/or technical personnel.

Team member Department Shift Phone

_____________________________ ___________________________ ____ ____________

_____________________________ ___________________________ ____ ____________

_____________________________ ___________________________ ____ ____________

_____________________________ ___________________________ ____ ____________

_____________________________ ___________________________ ____ ____________


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5.2 The Incident/Accident Analysis Team Leader (Supervisor)

The Incident/Accident Analysis team leader will:

1. Control the scope of team activities by identifying which lines of analysis should be pursued, referred to

another group for study, or deferred;

2. Call and preside over meetings;

3. Assign tasks and establish timetables;

4. Ensure that no potentially useful data source is overlooked; and,

5. Keep site management advised of the progress of the analysis process.

6.0 Determining the Facts

A thorough search for the facts is an important step in incident/accident analysis. During the fact-finding phase of

the process, the supervisor or the team members will:

1. Visit the scene before the physical evidence is disturbed;

2. Sample unknown spills, vapors, residues, etc., noting conditions which may have affected the sample; (Be

sure you sample using proper safety and health procedures.)

3. Prepare visual aids, such as photographs, field sketches, maps, and other graphical representations with the

objective of providing data for the analysis.

4. Obtain on-the-spot information from eyewitnesses, if possible. Interviews with those directly involved and

others whose input might be useful should be scheduled soon thereafter. The interviews should be

conducted privately and individually so that the comments of one witness will not influence the responses

of others.

5. Observe key mechanical equipment as it is disassembled. Include as-built drawings, operating logs, recorder

charts, previous reports, procedures, equipment manuals, oral instruction, change of design records, design

data, records indicating the previous training and performance of the employees involved, computer

simulations, laboratory tests, etc.

6. Determine which incident-related items should be preserved. When a preliminary analysis reveals that an

item may have failed to operate correctly, was damaged, etc., arrangements should be made to either

preserve the item or carefully document any subsequent repairs or modifications.

7. Carefully document the sources of information contained in the incident report. This will be valuable

should it subsequently be determined that further study of the incident or potential incident is necessary.

7.0 Determining the Cause

It is critical to determine the cause(s) of the accident. Therefore, the investigation will uncover:

1. Direct causes

2. Hazardous conditions

3. Unsafe behaviors

The supervisor or team will use appropriate methods to sort out the facts, inferences, and judgments. Even when

the cause of an incident appears obvious, the investigation team will still conduct a formal analysis to make sure

any oversight, or a premature/erroneous judgment, is not made.


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8.0 Recommending Corrective Actions and System Improvements

A recommendation for corrective action and system improvement will contain three parts:

1. The recommendation itself, which describes the actions and improvements to be taken to prevent a

recurrence of the incident.

2. The name of the person(s) or position(s) responsible for accomplishing actions and improvements.

3. The correction date(s).

9.0 Communicating Results

9.1 To prevent recurring incidents we will take two additional steps:

1. Document findings; and

2. Review the results of the analysis with appropriate personnel.

9.2 Incident documentation will address the following topics:

1. Description of the incident (date, time, location, etc.);

2. Facts determined during the analysis (including chronology as appropriate);

3. Statement of causes; and

4. Recommendations for corrective and preventive action (including who is responsible and correction date).

10.0 Review and approval

Appropriate operating, maintenance and other personnel will review all incident/accident analysis reports.

Personnel at other facilities will also review the report to preclude a similar occurrence of the incident.

Plan reviewed by __________________________________________ Date _______________________

__________________________________________ Date _______________________

__________________________________________ Date _______________________

Plan approved by __________________________________________ Date _______________________


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1. What two key conditions must exist before an accident occurs?

2. Are accidents always unplanned?

3. What are the characteristics of an effective incident/accident analysis program?

Review

Let’s review some of the important points about initiating the

accident investigation.

The basics


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Investigating Accidents

The three primary tasks of the accident investigator are to:

• Gather useful information,

• Analyze the facts surrounding the accident, and

• Write the accident report.

The Six-Step Process

Step 1 – Preserve and document the scene Step 2 – Collect the facts through interviews Step 3 – Develop sequence of events Step 4 – Determine causes Step 5 – Recommend improvements Step 6 – Write the report

Basic Steps for Conducting An

Accident Investigation/Analysis


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Step 1: Preserve and Document the Accident Scene

Why is it appropriate to begin the investigation immediately?

____________________________________________________

____________________________________________________

In this session, we take a look at strategies for preserving and documenting the

accident scene. We’ll learn why it is important to begin the investigation early-on,

when it’s “safe” to investigate. Next, we’ll cover how to secure the accident scene

once the investigation has been initiated. Finally, you’ll learn what the law says about

reporting accidents to OSHA.

The first two steps in the procedure help you gather accurate information about the accident.

What are effective methods to secure an accident scene?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

.


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SAMPLE ACCIDENT INVESTIGATOR’S KIT

Essential

Camera*

Tape recorder and spare cassette tapes

Tape measure - preferably 100 foot

Clipboard and writing pad

Graph paper

Straight-edge ruler (Can be used as a scale reference in photos)

Pens, pencils

Accident investigation forms

Flashlight

Strings, stakes, warning tap

* Digital cameras are not generally recommended is there is a possibility of

legal action, as digital images can be easily altered.

Helpful

Accident investigator’s checklist

Magnifying glass

Sturdy gloves

High visibility plastic tapes to mark off area

First aid kit

Identification tags

Scotch tape and masking tape

Specimen containers; plastic bags with ties

Compass

Ten 4-inch spikes

Hammer

Paint stick (yellow/black)

Chalk (yellow/white)

Protractor

Video camera

Have a ready-and-waiting accident investigator's kit. You won't be able to fulfill

this purpose unless you come prepared so make sure an accident investigation

kit is available for use.



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1. Make sketches large; preferably 8" x 10".

2. Makes sketches clear. Include information pertinent to the investigation.

3. Include measurements.

4. Print legibly. All printing should be on the same plane.

5. Indicate directions, i.e., N, S, E, W.

6. Always tie measurements to a permanent point, e.g., telephone pole, building.

7. Use sketches when interviewing people. You can mark where they were standing. Also,

the sketch can be used to pinpoint where photos were taken.

SKETCHING TECHNIQUES

Photo

Location

Point-

East

Height

8 Ft.

Height

8 Ft.

Height

8 Ft.

Height

8 Ft.

Height

8 Ft.

Example Sketch for a Fatality

Lumber Storage Area, ZYX Sawmill, Ltd.

N

Height

8 Ft.

Height

8 Ft.

Height

8 Ft.

Lumber Piles

Location of deceased (face down)

Direction of travel of deceased

Mr. J. Operator

Accident-Details

Time: 6.45 p.m.

Lighting: Dusk

Deceased: 6’1” Tall

Eye Level of Operator: 7’

Top of Load: 9’4”

Traveling Speed of Load:

Approx. 5 mph

Very Poor Operator

Visibility

22” Space


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An employee of PC Pallet was fatally crushed by a falling stack of bundled

lumber while picking up building material (2x4 lumber that was 16-feet long)

at a material-handling facility of another company (RRC). The victim was

identifying the bundles of lumber that were going to be purchased by PC

Pallet, while an employee of RRC was operating a powered industrial truck

(forklift) to move bundled lumber in the stacks. Bundles of lumber were

arranged in a row with four stacks. The front stack was four bundles high

(approximately 11 feet). The second and third stacks were each 6 bundles

high (approximately 16.5 feet). The fourth stack was 4 bundles high

(approximately 11 feet). The top (fourth) bundle of the first/front stack had

been moved by a RRC forklift operator and placed on the PC Pallet truck,

which was parked approximately 36 feet from the stacked lumber bundles.

As the third bundle of the first stack was being moved by the forklift, the top

four bundles of the second stack shifted and three of these bundles fell over

the remaining two bundles of the first stack and fatally struck the victim, who

was standing approximately 14 feet from the front stack of lumber. The

stacked lumber was placed on an earthen surface that was damp and had

been exposed to snow and fluctuating temperatures during the past week. It

was reported that the stacks had been leaning forward prior to the accident.

Accident Scenario – Sketch Exercise


Group Exercise: On a blank piece of paper, sketch the accident scene

for this scenario.


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Group Exercise:

What “documents” will you be interested in interviewing?

Record Why - What do you expect to find?

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

_________ _______________________________________________________

That's right...you don't just review records, you "interview" them by

asking questions. If you ask . . . they will answer.



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DOCUMENT ANALYSIS

This document covers the four areas that should be reviewed in determining the

root cause of hazards, accidents and incidents. It is not uncommon to find factors

in each of the four areas: Management, Employee, Equipment and Environment.

Management Checklist

1. Did supervisors detect, anticipate, or report an unsafe or hazardous condition?

2. Did supervisors recognize deviations from the normal job procedure?

3. Did supervisors and employees participate in job review sessions, especially for

those jobs performed on an infrequent basis?

4. Were supervisors made aware of their responsibilities for the safety of their

work areas and employees?

5. Were supervisors properly trained in the principles of accident prevention?

6. Was there any history of personnel problems or any conflicts with or between

supervisors and employees or between employees themselves?

7. Did supervisors conduct regular safety meetings with their employees?

8. Were the topics discussed and actions taken during the safety meetings

recorded in the minutes?

9. Were the proper resources (e.g., equipment, tools, materials, etc.) required to

perform the job or task readily available and in proper condition?

10. Did supervisors ensure employees were trained and proficient before

assigning them to their jobs?

11. Did management properly research the background and experience level of

employees before extending an offer of employment?

Yes No

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

Question #

_________

_________

_________

_________

Comments:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


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DOCUMENT ANALYSIS

Employee Checklist

1. Did a written or well-established procedure exist for employees to follow?

2. Did job procedures or standards properly identify the potential hazards of job

performance?

3. Were employees familiar with job procedures?

4. Was there any deviation from the established job procedures?

5. Did any mental or physical conditions prevent the employee(s) from properly

performing their jobs?

6. Were there any tasks in the job considered more demanding or difficult than

usual (e.g., strenuous activities, excessive concentration required, etc.)?

7. Was the proper personal protective equipment specified for the job or task?

8. Were employees trained in the proper use of any personal protective

equipment?

9. Did the employees use the prescribed personal protective equipment?

10. Were employees trained and familiar with the proper emergency procedures,

including the use of any special emergency equipment?

11. Was there any indication of misuse or abuse of equipment and/or materials

at the accident site?

12. Is there any history or record of misconduct or poor performance for any

employee involved in this accident?

13. If applicable, are all employee certification and training records current and

up-to-date?

14. Was there any shortage of personnel on the day of the accident?

Yes No

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

___ _____

____ ____

____ ____

____ ____

____ ____

____ ____

Question #

_________

_________

_________

_________

Comments:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


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DOCUMENT ANALYSIS

Equipment Checklist

1. Were there any defects in equipment (including materials and tools) that

contributed to a hazard or created an unsafe condition?

2. Were the hazardous or unsafe conditions recognized by management,

employees, or both?

3. Were the recognized hazardous conditions properly reported?

4. Are existing equipment inspection procedures adequately detecting hazardous

or unsafe conditions?

5. Were the proper equipment and tools being used for the job?

6. Were the correct/prescribed tools and equipment readily available at the job

site?

7. Did employees know how to obtain the proper equipment and tools?

8. Did equipment design contribute to operator error?

9. Was all necessary emergency equipment readily available?

10. Did emergency equipment function properly?

11. Is there any history of equipment failure for the same or similar reasons?

12. Has the manufacturer issued warnings, Safe-Alerts, or other such

information pertaining to this equipment?

13. Were all equipment guards and warnings functioning properly at the time of

the accident?

Yes No

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

Question #

_________

_________

_________

_________

Comments:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


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DOCUMENT ANALYSIS

Environment Checklist

1. Did the location of the employees, equipment, and/or materials contribute to

the accident?

2. Were there any hazardous environmental conditions that may have contributed

to the accident?

3. Were the hazardous environmental conditions in the work area recognized by

employees or supervision?

4. Were any actions taken by employees, supervisors, or both to eliminate or

control environmental hazards?

5. Were employees trained to deal with any hazardous environmental conditions

that could arise?

6. Were employees not assigned to a work area present at the time of the

accident?

7. Was sufficient space provided to accomplish the job?

8. Was there adequate lighting to properly perform all the assigned tasks

associated with the job?

9. Did unacceptable noise levels exist at the time of the accident?

10. Was there any known leak of hazardous materials such as chemicals,

solvents or air contaminants?

11. Were there any physical environmental hazards, such as excessive vibration,

temperature extremes, inadequate air circulation, or ventilation problems?

12. If applicable, were there any hazardous environmental conditions, such as

inclement weather, that may have contributed to the accident?

13. Is the layout of the work area sufficient to preclude or minimize the possibility

of distractions from a passerby or from other workers in the area?

14. Is there a history of environmental problems in this area?

Yes No

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

____ ____

Question #

_________

_________

_________

_________

Comments:

______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


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Quiz

Let’s review some of the important points about preserving and

documenting the accident scene.

1. What's the most practical way to secure an accident scene?

2. What might be the result if the investigation is not initiated as soon

as possible?

3. If a workplace fatality or hospitalization of three or more employees

occurs, the affected employer must notify OSHA within _____.

a. twenty-four hours c. eight hours

b. sixteen hours d. four hours

4. When documenting the scene, one of the biggest challenges facing

the investigator is to:

a. determine who is to blame

b. determine what is relevant

c. determine who is in charge

d. determine who is liable



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Step 2: Collect Facts through Interviews

Introduction

Once you have initially preserved and documented the accident scene, it becomes

important to start digging for details through the interview process. Conducting an

interview is perhaps the most difficult part of an investigation. This section will help

you understand how to organize the interview and obtain accurate information.

When is it best to interview? Why?

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Whom should we interview? Why?

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Where should we conduct the interview?

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

When should we NOT interview?

________________________________________________________

________________________________________________________


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Group Exercise: Cooperation is the Key

Purpose. Gaining as much information as possible about

an accident is extremely important. Interviewing witnesses

is both a science and an art, and can make the difference

between a failed or a successful accident investigation.

This exercise will help you gain a greater awareness of those

interviewing questions you need to prepare for the

interview and help ensure your success as an investigator. Remember,

you must communicate a message of cooperation, not intimidation.

Instructions. Read the accident scenario provided. Your group is located at the

scene of the accident (classroom) and your job now is to ask follow-up questions to

gather information about the accident. Identify the person you are interviewing and

the questions you will ask.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Did You Get the Facts?



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Mary Alice Conlin - Application Case Study (Page 1)

The accident occurred on a Walsh 55-ton full-revolution mechanical power

press. Mary Alice Conlin lost three fingers and part of her thumb on the

right hand when she reached into the press to extract a part.

The maintenance man did not secure the shield a week before the injury

event as he was in a hurry to get to another machine breakdown. Besides,

he needed a part to fix this press and had to wait for the part to be ordered.

The press was foot pedal operated with a point of operation guard. The foot

pedal was not guarded. The guard had a flip-up plexi-glass shield on the

front that was hinged, not fixed in place (secured). The employee (Mary

Alice) was removing a piece of metal that was stuck in the die. The guard

was flipped open. While removing the scrap part, she accidentally stepped

on the foot pedal. The employee lost 3 fingers and part of her thumb on the

right hand. She had been a press operator for 3 days. At approximately

9:00 a.m., employee #2 heard Mary Alice scream and ran to her while

shouting for help.

Employee #3, the designated first aider, heard the scream. He grabbed his

first aid kit and ran to Mary Alice to render first aid treatment. At

approximately 9:05 a.m., employee #2 ran to the supervisor’s office and the

rescue squad was called. Approximately 10 minutes later, the rescue squad

arrived and rendered treatment to stabilize Mary Alice who appeared to be

in shock. The rescue squad transported Mary Alice to the emergency room

at 9:30 a.m.


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INTERVIEWING QUESTIONS

WHO? WHERE?

Who was injured

Who saw the accident

Who was working with the employee

Who had instructed/assigned the employee

Who else was involved

Who else can help prevent recurrence

Where did the accident occur

Where was the employee at the time

Where was the supervisor at the time

Where were fellow workers at the time

Where were other people who were involved at the time

Where were witnesses when accident occurred

WHAT? WHY?

What was the accident

What was the injury

What was the employee doing

What had the employee been told to do

What tools was the employee using

What machine was involved

What operation was the employee performing

What instructions had the employee been given

What specific precautions were necessary

What specific precautions was the employee given

What protective equipment should have been used

What protective equipment was the employee using

What had other persons done that contributed to the accident

What problem or questions did the employee encounter

What did the employee or witnesses do when the accident occurred

What extenuating circumstances were involved

What did the employee or witnesses see

What will be done to prevent recurrence

What safety rules were violated

What new rules are needed

Why was the employee injured

Why and what did the employee do

Why and what did the other person do

Why wasn’t protective equipment used

Why weren’t specific instructions given to the employee

Why was the employee in the position

Why was the employee using the tools or machine

Why didn’t the employee check with the supervisor when the employee noted things weren’t as they should be

Why did the employee continue working under the circumstances

Why wasn’t the supervisor there at the time

WHEN? HOW?

When did the accident occur

When did the employee start on that job

When was the employee assigned on the job

When were the hazards pointed out to the employee

When had the employee’s supervisor last checked on job progress

When did the employee first sense something was wrong

How did the employee get injured

How could the employee have avoided it

How could fellow workers have avoided it

How could supervisor have prevented it - could it be prevented


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Quiz

Let’s review some of the important points about collecting

information on the accident.

1. What relevant information might be obtained by reviewing the

OSHA Injury and Illness records?

2. What is the purpose of the interview process. How do you best

achieve that purpose?

3. Which of the following is an effective interview techniques?

a. Ask "why-you" questions

b. Ask open-ended questions

c. Interview in a crowd

d. Encourage fault-finding

4. Why is it important to repeat the facts and sequence of events back

to the interviewee?



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Group Exercise: Develop the Sequence

Use the information gathered about the accident described in

the interview exercise to construct a sequence of events

listing the events prior to, during, and after the accident.

Instructions. Determine the injury event and list the events that led up to the

injury. Once you start the sequence, ask "What happened next?“ to determine the next

event.

Event __ ____________________________________________________________

Event __ __________________________________________________________________

Event __ __________________________________________________________________

Event __ __________________________________________________________________

Event __ ____________________________________________________________

Event __ __________________________________________________________________

Event __ __________________________________________________________________

Event __ __________________________________________________

Event __ ____________________________________________________________

Event __ ____________________________________________________________

Event __ ____________________________________________________________

Event __ ____________________________________________________________

Event __ ____________________________________________________________

Step 3: Develop the Sequence of Events


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Quiz

Let’s review some of the important points about developing a

sequence of events on the accident.

1. An “event” occurs when one _______ performs an _______.

2. Name the actor(s)/action(s) for the following: “Robert used a wrench to pound

a nail.”

3. Developing the sequence of events is critical in the accident “analysis” process

to:

a. Find out who to interview

b. Fix the system

c. Place the blame

d. Document the scene

Step 3: Develop the Sequence of Events


29


Multiple Causation and the Accident Weed

Injury or

Illness

1. Direct Causes of the Injury • Always the harmful transfer of energy.

• Kinetic, thermal, chemical, etc.

• Contact with, exposure too, etc.

2. Indirect (Surface) Causes of Accident

Primary Surface Causes

• Produces the accident

• Unique hazardous condition/unsafe behavior

• Exists/Occurs close to the injury event

• Involves the victim, possibly others

Contributing Indirect Causes

• Contributes to the accident

• Unique hazardous condition

• Inappropriate/unsafe behavior

• Exists/occurs more distant from the accident

• Exists/occurs anytime, anywhere by anyone

3. Basic (Root) Causes of the Accident

Inadequate system implementation

• Failure to carry out safety policies, programs,

plans, processes, procedures, practices

• Pre-exist indirect causes

• Under control of management

• Failure can occur anytime, anywhere

• Produces common indirect causes

Inadequate system design

• Poorly written or missing policies, programs,

plans, processes, procedures, practices

• Pre-exist indirect causes

• Under top management control

• Produces inadequate implementation

Fails to inspect

No recognition planInadequate training plan

No accountability policy No inspection policy

No discipline procedures

Outdated hazcom programNo orientation process

Unguarded machine Horseplay

Fails to trainTo much work

Defective PPE Fails to report injury

Inadequate training

Create a hazard

Fails to enforce

Untrained worker

Broken tools

Ignore a hazard

Lack of time

Inadequate labeling

No recognition

Cuts

Burns

Lack

of

vis

ion

Strains

No

mis

sio

n s

tate

men

t

Chemical spill

Any way you look at it, design is the key to

an effective safety management system.

If design is flawed, yet perfectly implemented, the

system fails. If design is perfect, yet

implementation is flawed, the system fails as a

result of design flaws in other related processes.

Step 4: Determine the Causes

Conditions

Acts

System Analysis

Injury Analysis

Event Analysis

Too much work


30


Steps in Root Cause Analysis: Three Levels of Cause Analysis

1. Injury Cause Analysis. Analyze the injury event to identify and describe the nature of the

harmful transfer of energy that caused the injury or illness.

Examples:

• Laceration to right forearm resulting from contact with rotating saw blade.

• Contusion from head striking against/impacting concrete floor.

2. Indirect (Surface) Cause Analysis. Analyze events to determine specific hazardous

conditions and unsafe or inappropriate behaviors.

a. For primary indirect causes. Analyze events occurring just prior to the injury

event to identify those specific conditions and behaviors that directly caused the

accident.

Examples:

• Event x. Unguarded saw blade. (condition or behavior?)

• Event x. Working at elevation without proper fall protection. (condition or

behavior?)

b. For contributing indirect causes. Analyze conditions and behaviors to determine

other specific conditions and behaviors (contributing causes) that contributed to the

accident.

Examples:

• Supervisor not performing weekly area safety inspection. (condition or

behavior?)

• Fall protection equipment missing. (condition or behavior?)

3. Root Cause Analysis. Analyze system weaknesses contributing to indirect causes.

a. For inadequate implementation. Analyze each contributing condition and

behavior to determine if weaknesses in carrying out safety policies, programs, plan,

processes, procedures and practices (inadequate implementation) exist.

Examples:

• Safety inspections are being conducted inconsistently.

• Safety is not being adequately addressed during new employee orientation.

b. For inadequate design. Analyze implementation flaws to determine the underlying

inadequate formal (written) programs, policies, plans, processes, procedures and

practices.

Examples:

• Inspection policy does not clearly specify responsibility by name or position.

• No fall protection training plan or process in place.


31



Class Exercise

List some of the possible causes of the accident according to the multiple

cause theory. Don’t spend a lot of time on this exercise. There will be

additional exercises to determine direct, indirect and root causes of the

accident.

What may be the cause of causes of the accident according to the

multiple cause theory?

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

Direct Cause

Provide the information below for the accident scenario.

Injury Result Caused by (transfer) Object/Energy Source

_________________________________________________________


32


ACCIDENT TYPES THAT DESCRIBE TRANSFER OF ENERGY

STRUCK-BY. A person is forcefully struck by an object. The force of contact is

provided by the object. Example -- a pedestrian is truck by a moving vehicle.

STRUCK-AGAINST. A person forcefully strikes an object. The person provides the

force. Example -- a person strikes a leg on a protruding beam.

CONTACT-BY. Contact by a substance or material that by its very nature is harmful

and causes injury. Example -- a person is contacted by steam escaping from a pipe.

CONTACT-WITH. A person comes in contact with a harmful material. The person

initiates the contact. Example -- a person touches the hot surface of a boiler.

CAUGHT-ON. A person or part of his/her clothing or equipment is caught on an

object that is either moving or stationary. This may cause the person to lose his/her

balance and fall, be pulled into a machine, or suffer some other harm. Example – a

person snags a sleeve on the end of a hand rail.

CAUGHT-IN. A person or part of him/her is trapped, stuck, or otherwise caught in

an opening or enclosure. Example -- a person’s foot is caught in a hole in the floor.

CAUGHT-BETWEEN. A person is crushed, pinched or otherwise caught between

either a moving object and stationary object or between two moving objects.

Example -- a person’s finger is caught between a door and its frame.

FALL TO SURFACE. A person slips or trips and falls to the surface he/she is

standing or walking on. Example -- a person trips on debris in the walkway and falls.

FALL-TO-BELOW. A person slips or trips and falls to a surface level below the one

he/she was walking or standing on. Example -- a person trips on a stairway and falls

to the floor level below.

EXERTION. Someone over-exerts or strains him or herself while doing a job.

Examples -- a person lifts a heavy object or a person repeatedly twists the torso to

place materials on a table. Interaction with objects, materials, etc., is involved.

BODILY REACTION. Caused solely from stress imposed by free movement of the

body or assumption of a strained or unnatural body position.. Example - a person

bends or twists to reach a valve and strains back.

EXPOSURE. Over a period of time, someone is exposed to harmful conditions.

Example -- a person is exposed to levels of noise in excess of 90 dBa for 8 hours.


33



Group Exercise: Event Analysis (Indirect cause)

Determine the primary indirect causes for the accident scenario.

Look for specific employee acts/behaviors and hazardous conditions

that caused the injury.

Examples

Event x. Unguarded saw blade. (act or condition?)

Event x. Working at elevation without proper fall protection. (act or condition?)

Event

Act(s)_____________________________________________________

Condition(s)________________________________________________

Event

Act(s)_____________________________________________________

Condition(s)________________________________________________

Event

Act(s)_____________________________________________________

Condition(s)________________________________________________

The contributing indirect causes are also specific acts/behaviors and

conditions.

Examples:

Supervisor not performing weekly area safety inspection. (act or condition?)

Fall protection equipment missing. (act or condition?)

Responsible person not trained on how to hook up harness. (act or condition?)

Event

Act(s)_____________________________________________________

Condition(s)________________________________________________

Event

Act(s)_____________________________________________________

Condition(s)________________________________________________


34


Group Exercise: System Analysis (Root Cause)

– Get to the roots by asking Why? Why? Why?

Instructions. Analyze each indirect cause to identify

potential root cause(s) that contributed to or produced the

accident.

Determine system implementation weaknesses. Look for the common

behaviors that represent inadequate implementation of safety programs and

processes. It’s important to understand that poor implementation of one program area

may be the result of poor implementation in another safety management program area:

Management commitment and accountability

Employee involvement

Worksite analysis

Hazard identification & control

Education & training

Safety system evaluation

System Implementation Root Causes

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________



35


Group Exercise:

Determine system design weaknesses. Then ask “why” to determine the

inadequate/missing policies and plans that caused them. These are common

conditions.

• Inspection policy does not clearly specify responsibility by name or position

• No fall protection training plan or process in place

• Procedures for administering corrective actions absent from the

accountability plan

System Design Root Causes

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________



36


Direct Cause of Injury

Hazardous Conditions Unsafe Behaviors

Team Exercise: Digging up the roots 1. Enter the direct cause of injury within the box below.

2. List hazardous condition and unsafe behavior from the sequence of events.

3. Determine contributing causes for the hazardous

condition and unsafe act/behavior.

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

Contributing conditions/behaviors

Implementation root causes

Design Root Causes

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

__________________________________ _________________________________

________________________________

________________________________


__________________________________ _________________________________


37


1. Injury Event (injury, illness, other losses). Pinpoint the problem and enter within 1st rectangle. 2. Sequence. Develop sequence of events from start to finish, based on interviews and physical evidence. Describe each event as an occurrence with one noun/verb. Describe the events precisely as they happen. Enter into the 2nd rectangle. 3. Injury Analysis (direct cause). Analyze the injury event to identify and describe the direct cause of the injury and enter within the 3rd rectangle. 4. Event Analysis (indirect cause-acts/conditions). After the sequence of events is established, the causes of each event can be described. This involves asking why, why, why, why, why. You may decide not to ask questions for all events in the sequence, just the ones critical for understanding the causes. Determine indirect causes (hazardous condition and unsafe behavior) from the sequence of events. Enter within the 4th rectangle. 5. System Analysis (root cause). The last step is to find the root causes, the procedures, standards, controls that management did not design or failed to implement. Continue asking “why” in order to develop the information needed to establish the root causes. Root causes are usually not physical things. They are program and/or related behavioral inadequacies. Determine system design and system implementation causes for each of the indirect causes. Enter in 5th rectangle.

Fix the System . . Not the Blame!Fix the System . . Not the Blame!

The Situation

(injury, illness, other

losses)

Ike in hospital

Forklift a total loss

Lost production

EPA involvement

Lawsuits

3. Injury Analysis–

Direct Cause

Impact following a 12 foot fall

from dock to concrete floor,

causing a broken back

4. Event Analysis-

Indirect Cause

(act or condition)

Not inspecting vehicle (act)

Ike not trained (condition)

Vehicle driven without

sufficient brake fluid

(condition)

Protective barrier removed

from dock, presenting

exposure (condition)

Supervisor failed to inspect for

barrier (act)

2. Sequence of Events

1. Brake fluid leaked from master cylinder overnight

2. Ike assigned to operate forklift, 2nd day on job; no training

3. Brakes not checked before using forklift

4. Barrier guard removed from dock to install new conveyors

5. Barrier guard not replaced

6. Brakes on forkli ft failed

7. Ike drove off the dock

8. Rescue squad transported Ike to hospital

9. Cleanup of hazardous materials started

10.EPA contacted

1. Injury Event

Brakes failed and Ike

drove off the dock

5. System Analysis-Root

Cause (procedures,

standards, controls)

Operator not trained (implementation)

Selection criteria less than adequate (design)

Maintenance procedures not adequate

(implementation/design)

No inspection policy (design)

Here is another way to put the information together.


38


Quiz

Let’s review some of the important points about cause analysis.

1. Which theory below states, “An accident is the result of a series of related events:

Eliminate any one event and you prevent a future accident?”

a. Single event theory

b. Domino theory

c. Multiple cause theory

d. System weakness theory

2. The three phases of cause analysis are:

3. The underlying safety system weakness are called the:



39


Step 5: Develop Recommendations

Group Exercise: Recommending Corrective Actions

Instructions: In this exercise you’ll develop and recommend immediate

actions to correct the surface causes of an accident. 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.

Recommendation: ________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Group Exercise: Recommendations for System Improvements

Fix the system…not the blame

Instructions. Develop and write a recommendation to improve one or

more policies, plans, programs, processes, procedures, and

practices related to the accident scenario.

Recommendation: _____________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


40


Answer the following six questions to help develop and justify recommendations.

1. Pinpoint the problem

2. What is the history of the problem?

3. Pinpoint the specific solution.

4. Who is the decision-maker?

5. What motivates the decision-maker?

6. What will be the cost/benefits if the recommendation is

approved and the predictable cost/benefits if not?

Determine the costs

To calculate direct cost, enter the following:

Most likely injury:

Total value of the insurance claim for injury or illness $

To calculate indirect cost, multiply direct cost by a cost multiplier.

The cost multiplier that you use will depend on the size of the direct cost.

If your directcost is:

Use this costmultiplier:

$0 - $2,999 4.5

$3,000 - $4,999 1.6

$5,000 - $9,999 1.2

$10,000 or more 1.1

Direct Cost x Cost Multiplier = Indirect Cost

$ = $

What are the total direct and indirect accident costs?

Direct Costs $ ________ + Indirect Costs $ __________ = $_________

Return on Investment (ROI): Benefits = Costs minus investment

ROI = Benefits =

Investment


41


Quiz

Let’s review some of the important points about developing

recommendations.

1. (Fill in the blank) When making recommendations, we need to propose

corrective actions ____ system improvements.

a. instead of

b. or

c. rather than

d. and

2. Engineering controls include all of the following except:

a. Substitution

b. Enclosure

c. Rescheduling

d. Redesign

3. Which control strategy is most effective in eliminating hazards?

a. Engineering Controls

b. Management Controls

c. PPE Control

d. Personnel Controls

4. All of the following are safety management system improvements except:

a. Writing a new safety policy.

b. Establishing a proactive incentive program.

c. Placing a guard on a table saw.

d. Revising an accident investigation form.

Step 5: Develop Recommendations


42


ACCIDENT INVESTIGATION REPORT

Date:___________________

Accident Investigator(s) ___________________ Dept. ______________ Tel #____________________

____________________________________________________________________

Section I. BACKGROUND

WHO was involved or injured?

Employee:

Address:

Job Title: Department: Length of Service:

Phone: Home: Work:

Date of birth: Date hired: Male/Female

Name of physician or other health care professional:

Name/Location of Treatment Center:

Was employee treated in an emergency room: Yes/No

Was employee hospitalized overnight? Yes/No

WHEN did accident/incident occur?

Date of Injury or Illness:

Time of Accident: ___ AM/PM Time Employee began work: ___ AM/PM

Date Accident Reported:

WHERE did the accident/incident occur?

Department: Location: Equipment:

WHAT happened?

What was employee doing just before accident occurred:

What happened:

What was the injury or illness:

What object or substance directly harmed the employee:

WITNESSES: Attach witness information and statements


43


Section II. DESCRIPTION OF ACCIDENT (Describe sequence of events prior to, during, and immediately

after the accident. Attach separate page if necessary)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Section III. FINDINGS AND JUSTIFICATIONS (Attach separate page if necessary)

• Indirect Cause(s) – Unsafe conditions and/or behaviors at any level of the organization;

& justification: Describe evidence or proof that substantiates your findings.

__________________________________________________________________________

__________________________________________________________________________

• Root Cause(s) – Missing/inadequate programs, plans, policies, processes, procedures; &

justification: Describe evidence or proof that substantiates your findings.

__________________________________________________________________________

__________________________________________________________________________

Section IV. RECOMMENDATIONS (Attach separate page if necessary)

1. Immediate Corrective Actions (To eliminate or reduce the hazardous conditions/unsafe

behaviors that directly caused the accident.)

_______________________________________________________________________________

_______________________________________________________________________________

Results (Describe the intended results and positive impact of the change.)

_______________________________________________________________________________

2. Long Term Corrections (policies, procedures, training, etc. to ensure unsafe conditions and/or

practices do not recur)

_______________________________________________________________________________

_______________________________________________________________________________

Results (Describe the intended results and positive impact of the change.)

_______________________________________________________________________________

Section V. SUMMARY (Brief review of the causes of the accident and recommendations for corrective

actions, including estimated costs of accident and costs and benefits of corrective action)

_______________________________________________________________________________

Section VI. REVIEW AND FOLLOW-UP ACTIONS (Appropriate, timely, etc.)

Immediate Corrective Actions Taken:

Responsible Individual:

Date Correction Due:

Date Closed:

Long Term (System Improvements) Made:

Responsible Individual:

Date Correction Due:

Date Closed:

Person(s) monitoring status of follow-up actions: _______________________

Prepared by __________________Title _________________ Date ________

Reviewed by _________________ Title _________________ Date ________

Reviewed by _________________ Title _________________ Date ________

Section VII. ATTACHMENTS (Photos, sketches, interview notes, etc.)


44


1. Your primary objective, as an accident investigator, is to:

a. inform the employer about options

b. place blame on those responsible

c. hold the employer accountable for compliance with OSHA

d. uncover the causal factors that contributed to the accident

2. The accident report form should be designed to make it possible to determine:

a. indirect causes

b. root causes

c. direct causes

d. All of the above

3. The accident report should not be considered closed until:

a. It is signed by the investigators

b. It is presented to management

c. All actions are complete

d. The accident is recorded on the OSHA forms

Step 6: Write the Report

Let’s review some important points about writing the report.


45


Group Exercise:

Putting it All Together

Instructions: Now that you’ve been introduced to the six-

step process, it’s time to do an accident investigation on

your own. Using some of the training aids from the

course (Sequence of Events, Cause Analysis Diagram,

Report) conduct your own investigation. This exercise

will give you practice in completing using a lot of the

information gained from this course. Be thorough and

use extra paper if needed.

Putting It Together

Participant Workbook(3)(1)

Documents

Transcript of Participant Workbook(3)(1)