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Accident Investigation, Analysis

and Reporting

Engr. Alexander B. Trillana 1


OSH Consultant
AGENDA
Application
Definition
Types of Accidents
Accident Investigation, Reporting and
Follow-Up
Table Top Exercises

2
Application
Kinds of Accidents Requiring Investigation
Fatality or Death
Lost Time Accident or Lost work day
Restricted Work Cases or Light Duty
Medical Treatment Cases
First Aid Cases
Major property damage
Near-miss incidents with potential for serious
injury or major property damage

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THE WORK ACCIDENT

A Work Accident shall mean an


unplanned or unexpected occurrence
that results in personal injury, property
damage, work stoppage or interference
or combination thereof which arises out
of and in the course of employment.

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A definition of an Accident
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THE INCIDENT OR NEAR MISS

An Incident or Near Miss is an unplanned


or unexpected occurrence that does not
result in personal injury, and property
damage.

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A definition of an Incident
Another definition of an Incident
The Domino Theory
Lack of Basic Immediate
Controls Causes Causes Accident Losses

Lack of Personal Unsafe Time Person


Controls Factors Acts Injuries
Date
Inadequate Job Unsafe Property
Controls Factors Conditions Place Damage

Inadequate Event Unquant


Compliance ified
to Losses
Controls

14
The Domino Theory
Classification of Losses
Personnel Injury:
Death, Person
Permanent Total Injuries
Disability
Property
Lost Time
Damage
Accident (LTA)
Non-Lost Time Unquant
Accidents ified
RestrictedWork Losses
Cases or Light
Duty Work
FirstAid Cases
Hospitalization & ECC Benefits (FACs) 15
The Losses from Accidents
Reporting Requirements
Accidents resulting in death or
permanent total disability must be
initially reported to DOLE within 24
hours of occurrence.
All other Types of Injuries such as
NLTAs, RWCs, FACs for reporting
on or before 20th day of the
following month using form IP-6
-Rule 1053.01 OSHS
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The Domino Theory
Types of Property Losses
Damages for
Reporting to DOLE: Person
Explosions of Injuries
boilers, air
receivers, Property
Damage
Collapse of crane,
derrick, hoist Unquant
Firecausing ified
damage to any Losses
room where
persons are
employed
Property Damage -Rule 1053.02 17
The Domino Theory
Accident Losses
Time
Time Person
Injuries
Date Date
Damage
Place to
Place Property
Event,
Occurrence Type of
Accident
Unquant
ified
(refer to types of Losses

accidents)
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Types of Employee Accidents
Exposure Accidents
Person suffers injury or illness as result of
exposure to harmful conditions such as:
Toxic gases, fumes, vapors, dusts
Extremes of heat or cold
High noise levels
Radioactive radiation, or intense light
Examples:
Carbon Monoxide

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Types of Employee Accidents
Struck-by Accident;
Person has been
contacted abruptly and
forcefully by some
object in motion
Example: being hit by
falling tool, struck by
moving vehicle, struck
by rolling drum
Other Examples:
Previous Accident
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Previous Accident
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Previous Accident
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Whole Picture

Arrow shows pivot point on Portal crane legs. All lifting


should have been carried out using top beam.
Mast had moved sideway

Employee was
standing here
and was trapped
Legs on portal crane
by bottom beam
moved in this direction
once lifted from the
bottom beam.
Sustained injuries

Workers legs trapped


in between pipes and
bottom beam of crane.
60 ton assisting crane
hook and slinging
point opposite injured
worker
37
Types of Accidents

Struck-By Accident:
An employee was watching a co-worker sledge a bolt into
place on a casting. He was not wearing eye protection.
After several blows had been struck, a sliver of steel broke
off the bolt struck him in the eye.

How could this injury been prevented?

Are any hazards or conditions in your work area that could


result in Struck By injuries?

How can you prevent them?

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Types of Employee Accidents
Contact-with Accident
A person has contacted some substance
or object capable of producing injury
Example: Contact with steam pipe, contact
with energized electrical conductor
Other Examples:
While exiting from a substation, boom truck
driver failed to lower boom, boom contacted
34.5KV energized line
Arm with third degree burn from high-voltage line.
Electrical burn on hand and arm.
Electrical Burns when using faulty drill
Dont ignore
LOTOTO
This Is Arc Flash!

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GaSHE- Hospital Safety Related to MEP Systems 9/28/2013
Types of Employee Accidents
Struck-against Accident
Person contacts abruptly and
forcefully some object

Example: Banging your head against a


low beam, striking a leg against an
open drawer
Other Examples:
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Types of Employee Accidents
Same Level Fall
Accident
Person falls to same
level he/she was
standing/walking
This type of accidents
usually involves slipping
or tripping
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52
Would you like one of
these in your foot?

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58
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60
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63
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Types of Employee Accidents
Different Level Fall Accident
Person falls below foot level on which
he/she was standing/walking

Example: Falling down from ladder


Other Examples:
One of the beams of the 16 tons K8 overhead crane had
been used as access by Mr. Chaco Mathew heading to K6
overhead crane to be repaired.
.

Adjacent monkey
ladder
Mr. Chaco Mathew
landed here.
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POTENTIAL FALLING ACCIDENT

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4 Video Clip
Painting Using Ladder
Shop Girl
Types of Accidents
Different Level Fall Accident:

A worker was standing on a platform 12 feet


above ground replacing a guard on the motor of a
bucket elevator. The platform did not have a
railing around it. When he stepped back he fell of
the platform.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Different Level Fall injuries?

How can you prevent them?

105
Types of Employee Accidents
Overexertion Accident
Person gets injured as
result of putting
excessive strain on some
part of his/her body
Example: Straining back
while lifting
heavy/awkward load
Other Examples:
Overexertion
Types of Accidents
Overexertion Accident:

A worker was attempting to carry a 12-foot


metal ladder in a vertical position. The top of
the ladder leaned sideways and he injured his
back while trying to hold the ladder from
falling.

How could this injury been prevented?

Are any hazards or conditions in your work


area that could result in Overexertion injuries?

How can you prevent them?

109
Types of Employee Accidents
Caught-on Accident
Person (or some part of persons
clothing) has become caught on some
protruding object

Example: Trouser cuff or sleeve caught


on a projecting piece of scrap or other
material
Other Examples:
Types of Employee Accidents
Caught Between Accident
Person is pinched, crushed or caught between
either a moving object and a stationary object or
between two moving parts
Example: Being crushed between the rear of a
truck in reverse and a loading dock
Other Examples:
Nov. 2, 2003 Rig Floor
Running at 130 rpm
Make sure all rotating parts have guards!
Types of Employee Accidents
Trapped-in Accident
Person is trapped in some enclosure, or
part of a persons body is caught in some
type of opening

Example: Worker stuck in a narrow opening


through which he attempted to crawl
Other Examples:
Hydrogen Sulfide

137
Hydrogen Sulfide

138
hydrogen sulfide concentration

Hydrogen Sulfide
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NOBODY GETS HURT

It only takes one breath!

ARGON GAS KILLED ME

PIPES ARE CONFINED SPACES.


DO NOT ENTER WITHOUT A PERMIT !
1/6/2011 0
EVERY ONE , EVERY DAY , EVERY TASK
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The Immediate Causes

Unsafe Acts
+
Unsafe Conditions
=
Accidents and Incidents

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Accidents / Incidents Triangle

1
LTA

10
Medical Treatment Cases

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Property Damages

600 Incidents or Near Misses


(indicators of Unsafe Acts /Conditions)

Statistics Study of Industrial Accidents


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Accidents / Incidents Triangle

To prevent one serious


accident, you have to identify
and correct the 600 potential
accidents, incidents, or near
misses.

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The Domino Theory
Immediate
Causes Accident Losses

Unsafe Time Person


Acts Injuries
Date
Unsafe Property
Conditions Place Damage

Event Unquant
ified
Losses

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The Immediate Causes
1. UNSAFE ACTS

*Operating equipment without training


and certificate
*Failure to give warning
*Failure to secure equipment, materials
*Running at to high a speed
*Tampering with safety devices.

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The Immediate Causes

2. UNSAFE CONDITIONS

-Poor housekeeping
-Poor ventilation
-High temperatures
-High Noise levels
-Radiation hazard.

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The Immediate Causes
2. UNSAFE CONDITIONS

-Guards, barriers not adequate


-PPE not adequate
-Defective equipment, materials, etc
-Restricted workplace
-Fire, flammable, explosion hazards.

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The Domino Theory
Basic Immediate
Causes Causes Accident Losses

Personal Unsafe Time Person


Factors Acts Injuries
Date
Damage
Job Unsafe Place to
Factors Conditions Property
Event
Unquant
ified
Losses

159
Basic Causes of Accidents
1. PERSONAL FACTORS
-Inadequate physical capacity as:
-lack of height,
-lack of heft, etc
-Physical Stress as:
-injury,
-fatigue,
-illness, diabetic condition, etc.
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Basic Causes of Accidents
1. PERSONAL FACTORS (continuation)
-Inadequate mental ability as:
-mental illness,
-mechanical inaptitude,
-poor judgment,
-memory failure,
-etc.

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Basic Causes of Accidents
1. PERSONAL FACTORS (continuation)
*Mental stress as:
-emotional overload,
-frustration,
-routine, demanding work,
-meaningless work.

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Basic Causes of Accidents
1. PERSONAL FACTORS (continuation)
*Lack of knowledge and training,
-lack of practice,
-lack of coaching,
-lack of skill
*Improper motivation
(this will be addressed in another
module on Safety Motivation).
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The Domino Theory
Basic Immediate
Causes Causes Accident Losses

Personal Unsafe Time Person


Factors Acts Injuries
Date
Damage
Job Unsafe Place to
Factors Conditions Property
Event
Unquant
ified
Losses

164
Basic Causes of Accidents
2. JOB FACTORS
*Inadequate leadership as poor
supervisory skills,
*Inadequate supervision
*Inadequate policy,
*Inadequate matching of capabilities
and job requirements, etc
*Inadequate Engineering as poor
layout.
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Basic Causes of Accidents
2. JOB FACTORS (continuation)
*Inadequate preparation of equipment,
*Poor assessment of loss exposures
*Inadequate Logistics as inadequate
specs,
*Inadequate handling of equipment, etc
*Inadequate maintenance or Poor PM,
*Poor lubrication program, etc.
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Basic Causes of Accidents
2. JOB FACTORS (continuation)

*Inadequate Tools and equipment


*Unavailability of proper tools,
*Human factors not considered, etc
*Inadequate work standards
*Too high requirements,
*Inconsistent work descriptions,
*Standards not updated.
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The Domino Theory
Lack of Basic Immediate
Controls Causes Causes Accident Losses

Lack of Personal Unsafe Time Person


Controls Factors Acts Injuries
Date
Inadequate Job Unsafe Property
Controls Factors Conditions Place Damage

Inadequate Event Unquant


Compliance ified
to Losses
Controls

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Loss of Control
o Inadequate Controls are common cause of confusion and failure
of controls
not specific
not clear
not high
o Adequate Controls are:
Specific
Measurable
Achievable
Realistic
Time bound

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Start of: Accident Investigation
Reporting and Follow-up

Let us start with the Domino Theory


1 Role of Investigation in Accident
Prevention
2 Introduction to Accident Investigation
3 Conducting the Accident Investigation
4 Reporting the Investigation
5 Follow-up
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Role of Investigation in
Accident Prevention
It is the source of our safety
know-how
Rules, procedures, regulations,
practices
It is the source of learning about
our total operation/ process
Attitude of employees, supervisors,
managers

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Role of Investigation in
Accident Prevention
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 job
Evaluation of corrective actions
To determine if corrective actions are effective in
preventing similar accidents
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Warning!

Wrong reasons to conduct accident


investigation
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

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The Accident
Investigation Process
1. Investigation Phase
2. Reporting Phase
3. Follow-up Phase

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The Accident
Investigation Process
1. Investigation Phase
Establish relevant accident facts
Who (numbers involved), what, when, where, why
and how / how much damage cost
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
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The Accident
Investigation Process
2. Investigation Phase
Complete the accident report form
Follow company procedures
Review completed report by appropriate
higher level of management
These are the weakest steps of the accident
prevention process

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Warning! Problems of Not
Reporting Accidents
Nothing learned from unreported
accidents
Accident causes not corrected
Infections/ aggravation of injury
Practice of not reporting tends to spread.

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Warning! Problems of Not
Reporting Accidents
Fear of reprisal from supervisor
Fear of getting bad reputation
Fear of medical treatment
Fear of embarrassment
Not wanting to lose work time
Not wanting an accident on their record
Not wanting to ruin a safety record
Other reasons? 178
The Accident
Investigation Process
3. Follow-up Phase
Assignment of corrective actions
Who is going to do what, and when
Assignments and completion dates must
be monitored / reviewed periodically
This ensures quality reports for supervisors

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Conducting the Accident
Investigation
Time and Place for accident investigation
Interviewing the Employee and Witnesses
Correct and Incorrect way to Interview
Major Investigation Errors/Mistakes to
avoid
Planning the Corrective Actions

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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
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Conducting the Accident
Investigation
Correct Ways to Interview
Interview one at a time in a private office
Seat the interviewee across a table, facing
you, and try to make him/her comfortable
Let employee know purpose of investigation is
to prevent recurrence
Let employee know purpose of investigation is
not to find fault
(Let us do this during the case study)
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Conducting the Accident
Investigation
Correct Ways to Interview
Let employee know purpose of investigation is
to prevent recurrence
How do you say it?
Let employee know purpose of investigation is
not to find fault only
How do you act? Remember, action speaks
louder than words.

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Conducting the Accident
Investigation
Correct Ways to Interview
Ask open-ended questions, for example:
Did you see when the forklift hit the wall?
Where were you standing? Did you have a
clear view?
Do not ask: Did you see the over-speeding
forklift? Why was he driving recklessly?

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Conducting the Accident
Investigation
Incorrect Ways to Interview
Let employee know purpose of investigation is
to fill out a report
Let employee know you know the facts
Ask vague questions
Let employee know purpose of investigation is
to find fault

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Interviewing Witnesses

1. Reassure the witness of the purpose of


the investigation
2. Let the witness tell the story
3. Begin with open-ended questions
4. Dont ask leading questions

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Interviewing Witnesses

5. Summarize
6. Ask for recommendations
7. Get written statements
8. Thank the employee
9. Close on a positive note
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ACCIDENT INVESTIGATION

Questions for reporting: WHO

- was injured?
- saw the accident?
- was working with the injured?
- had instructed/assigned the job to the injured?
- else was involved?
- has the information of events prior to the accident?

188
ACCIDENT INVESTIGATION

Questions for reporting: WHAT


- is the injury? - training had been given?
- is the damage or loss? - were the contributory causes
of the accident?
- was the injured doing?
- communication system was
- had the injured been
used?
instructed to do?
- is the state of health of the
-tools/equipment/machinery
injured?
were being used?
- safety rules were violated?
- did the injured & any
witnesses saw? - safety system and procedures
were there?

189
ACCIDENT INVESTIGATION

Questions for reporting: WHEN

- did the accident occur?


- did the damage become evident?
- did the injured start the job?
- was the explanation of hazard given?
- did the persons involved last have food &
rest?

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ACCIDENT INVESTIGATION

Questions for reporting: WHY


- did the injury occur? - was PPE not used?
- did the communication fail? - was there no safe system of
work?
- was the training not given?
- was there no safety
- were the unsafe condition
instruction given?
permitted?
- was the supervisor not
- was the hazard not spotted at
consulted when things
previous inspection?
started go wrong?
- was PPE not provided?
- was the supervisor not there
at the time?

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ACCIDENT INVESTIGATION

Questions for reporting: WHERE

- did the accident occur?


- did the damage occur?
- was the supervisor at that time?
- was the witness at that time?

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ACCIDENT INVESTIGATION

Questions for reporting: HOW

- did the injury occur?


- could the accident have been avoided?
- could have been the injury avoided?
- - could better design help?

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Conducting the Accident
Investigation
Major investigation errors to avoid
Reluctance to accept management
responsibility
Emphasis on a single cause only
Failure to establish root causes
Narrow interpretations of environmental
causes
Treating major injury accidents as minor
events, not considering HI-PO incidents.
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Accident Report and
Follow-up
Responsibility for Corrective Actions
Must be assigned
Must have completion date
Must be monitored to ensure corrective
actions have eliminated accident causes

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Workshop I - Gathering of Facts
I. Actual Accident or Simulated Accident
- Nature of Accident
- Parties involved/responsible person(s)
- Place of Accident
- Time and Date of Accident

II. Interview witnesses/victims


- 5Ws and 1 H develop at least 20 questions

III. Collected evidences, photographs, records review


15 minutes

IV. Presentation: Dramatization


10 minutes
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FALLING ACCIDENT

AL SHAQAB EQUESTRIAN
DOHA, QATAR
HANDLING THE VICTIM
CONTOLLING ACCIDENT SCENE
ACCIDENT INVESTIGATION
RECOMMENDATIONS
IMMEDIATE CORRECTIVE ACTION
LONG TERM CORRECTIVE
ACTION
FOLLOW-UP
TABLE TOP EXERCISE
Preventing Accident

Divide the participants into 4 groups.

Group brainstorming, analyze the assigned


previous accident scenario then using the
Domino theory, establish your appropriate
controls to prevent its recurrence .

Select your best presenter and discuss.


Types of Accidents
Exposure Accident:
Two workers assigned to monitor the boiler were
overcome by CO gases when the vapors from the
boiler engine accumulated in the boiler room. The
ventilation blower was not working properly.

How could this fatalities been prevented?

Are any hazards or conditions in your work area


that could result in Exposure accidents?

How can you prevent them?


229
Types of Accidents

Contact-By Accident: A truck driver was using


compressed air to unload acid
into a storage tank. During the
process the unloading hose
burst spraying him and other
workers with acid.

How could this injury been


prevented?

Are any hazards or conditions in


your work area that could
result in Contact-By injuries?

How can you prevent them?

230
Types of Accidents
Contact With Accident:

A worker was erecting a steel beam outside the


maintenance shop. While lifting the beam, the
beam made contact with overhead electrical
wires. He suffered serious electrical burns.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Struck-Against injuries?

How can you prevent them?

231
Types of Accidents
Struck-Against Accident:
The worker was attempting to remove the
coupling box from a roll stand. He positioned a
long metal bar in the hole at the top of the
coupling box and applied force to the box. The
bar slipped from the hole, causing him to fall
backwards. He struck his back against the mill
housing.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Struck-Against injuries?

How can you prevent them? 232


Types of Accidents
Same Level Fall Accident:

An office clerk was crossing railroad tracks to


pick up time sheets from the shipping office. As
he was crossing he stepped on one of the rails,
his foot slipped and he fell to the ground.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Same Level Fall injuries?

How can you prevent them?

233
Types of Accidents
Caught-On Accident:

A worker was getting off a moving railcar. As


he was getting of, the ring on his finger got
caught on the pipe coupling joining the two
sections of metal railing. His finger was
amputated from his hand.

How could this injury been prevented?

Are any hazards or conditions in your work


area that could result in Caught-On injuries?

How can you prevent them?

234
Types of Accidents
Caught Between Accident:

A worker was using a scraper to push coal spillage


back into a coal conveyor. As he was pushing coal
back into the conveyor his glove got caught
between the belt and an idler roll.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Caught Between injuries?

How can you prevent them?


235
Types of Accidents
Trapped-In Accident:

A worker entered a lateral section of sewer pipe


to inspect the lining. When he reached a
vertical section he fell inside and was unable to
climb out. He was rescued by using a retrieval
line.

How could this injury been prevented?

Are any hazards or conditions in your work area


that could result in Trapped-In accidents?

How can you prevent them?

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Hierarchy of Controls
Most effective

Eliminate

Substitute

Engineering

Admin
Training

PPE

Emergency Response Least effective


Preventing Accidents
REQUIRES A

TEAM EFFORT
238
End of Module:
Accident Investigation, Analysis
and Reporting

THANK YOU

Engr. Alexander B. Trillana 239


OSH Consultant