Professional Documents
Culture Documents
On average, the
indirect costs of
accidents exceed the
direct costs by a 4:1
ratio
OUTCOMES OF ACCIDENTS
POSITIVE ASPECTS
Accident investigation
Prevent recurrence
Change to safety programs
Change to procedures
Change to equipment design
The Aim of the Investigation
The key result should be to prevent a
recurrence of the same accident.
Fact finding:
What happened?
What was the root cause?
What should be done to prevent recurrence?
It is not to assign blame
The Investigation
DESIGN (equipment/material)
ENVIRONMENTAL
Noise
Vapors, fumes, dust
Light
Heat
CONTRIBUTING FACTORS
DESIGN
Workplace layout
Design of tools &
equipment
Maintenance
CONTRIBUTING FACTORS
SYSTEMS &
PROCEDURES
Lack of systems &
procedures
Inappropriate
systems &
procedures
Training in
procedures
Housekeeping
CONTRIBUTING FACTORS
HUMAN BEHAVIOR
..\..\diy_accident.wmv
DETERMINE CAUSES
Employee actions
Safe behavior, at-risk behavior
Environmental conditions
Lighting, heat/cold, moisture/humidity, dust, vapors, etc.
Equipment condition
Defective/operational, guards, leaks, broken parts, etc.
Procedures
Existing (or not), followed (or not), appropriate (or not)
Training
Was employee trained - when, by whom, documentation
Root Causes
Root causes are the management system
weaknesses that allowed the casual factor to
occur:
1. Equipment design process
2. Procedures
3. Supervision
4. Standards and Policies
5. Training
6. Communication Practices
7. Maintenance Practices
Root Causes
Root causes should be determined.
Example: An employee gets cut. What is the cause? It is
not just the saw or knife or the sharp nail.
Was it a broken tool and no one reported? Did someone
ignore a hazard because of lack of training, or a policy
that discourages reporting?
What are other examples of root causes? Enforcement
failure, defective PPE,
horseplay, no recognition plan, inadequate labeling.
FIND ROOT CAUSES
Unsafe
Unsafe Act Indirect Causes Condition
PREVENTING RECURRENCE
IDENTIFYING OUT-MODED
PROCEDURES
IMPROVEMENTS TO WORK
ENVIRONMENT
BENEFITS OF ACCIDENT
INVESTIGATION
INCREASED PRODUCTIVITY
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5 LG
16/10/2003
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