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Why Investigate Accidents?

p Prevent a recurrence with corrective


action
p Determine the cause
p Document your company¶s version of
the incident
p Completion of OSHA-required reporting
Investigation is 4 Step Process
p Control the Scene
p Gather Data

p Analyze Data

p Write Report
Who Investigates?
p Minor accident
À Supervisor
À Safety committee member
p Major accident
À Supervisor
À Safety committee member
À Safety manager
Investigator¶s Qualifications
p Accident investigation training
p Understanding of the importance
of investigation
p Ability to communicate details
When to Investigate?
p Immediately after
incident
À Witness memories
fade
À Equipment and clues
are moved

p ¦inish investigation
quickly.
Investigation Kit
p Camera and film
p Report forms, clipboard, pens
p Barricade tape
p ¦lashlight
p Tape measure
p Tape recorder
p Work gloves
Accident Investigation Goals
p Preparing the investigation team
p Conducting the investigation
The Accident Occurs
p Employee immediately reports the
accident to a supervisor
p Supervisor treats the injury or assesses
need for outside medical treatment
p Leave the accident scene intact
p Contact the accident investigation team
Control the Scene
p Provide medical care for injured
À ¦irst Aid
À On Scene Evaluation
À Transport for Medical Care
p Control existing hazards
À Prevent further injuries
À Get more help if needed
p Preserve evidence
Beginning the Investigation
p Gather investigation
team and kit
p Report to the scene
p Look at the big
picture
p Record initial
observations
p Take pictures
Gather Data
p Photos of accident scene
p Drawings & sketches & measurements
p Data
À Persons involved
À Date, time, location
À Activities at time of accident
À Equipment involved
À List of witnesses
Data Analysis List
p Accident Title
p Date, Time, Location
p Persons involved
p Witnesses
p Work & Environmental Conditions at
time of accident
p Immediate actions taken at scene
What¶s Involved?
p Who was
injured?
p Medication,
drugs,
or alcohol?
p Was employee
ill?
p Double shift or
rotating shifts?
What Was Involved?
p Machine, tool, or equipment
p Chemicals
p Environmental conditions
p Production schedule
Time of Incident
p Date and time?
p Normal shift?
p Employee coming
off a vacation?
Incident Location
p Work area
p On, under, in, near
p Off-site address
p Doing normal job duties
Incident Activities
p Motion conducted at time of incident
p Repetitive motions?
p Type of material being handled
Unsafe Acts
p List all unsafe acts involved in the accident
p Examples of unsafe acts
À Unauthorized operation of equipment
À Running - Horse Play
À Not following procedures
À By-passing safety devices
À Not using protective equipment
À Under influence of drugs or alcohol
À Taking short-cuts
Unsafe conditions
p List all unsafe conditions involved in the
accident
p Examples of unsafe conditions
À Ergonomic Hazards
À Environmental hazards
À Inadequate housekeeping
À Blocked walkways
À Improper or damaged PPE
À Inadequate machine guarding
Incident Description
p Details so reader
can clearly picture
the incident
p Specific body
parts affected
p Specific motions
of injured employee
just before, during, and
after incident
Information Interviews
p Gather just the facts« make no
judgments or statements
p Conduct interviews one on one
p Be friendly but professional
p Conduct interviews near the scene in
private
p Interview all supervisors
Interviewing Tips
p Discuss what happened leading
up to and after the accident
p Encourage witnesses to describe
the accident in their own words
p Don¶t be defensive or judgmental
p Use open-ended questions
Witnesses
p Who witnessed the incident?
p Was a supervisor or lead person nearby?
p Where were other employees?
p Why didn¶t anyone witness the incident?
Ask all witness
p Name, address, phone number
p What did you see
p What did you hear
p Where were you standing/sitting
p What do you think caused the accident
p Was there anything different today
Ask Supervisors
p What is normal procedure for
activities involved in the accident
p What type of training persons
involved in accident have had.
p What, if anything was different today
p What they think caused the accident
p What could have prevented the
accident
Analyze Data
p Gather all photos, drawings, interview
material and other information collected
at the scene.
p Determine a clear picture of what
happened
p ¦ormally document sequence of events
Causal ¦actors
p Try not to accept single cause theory
p Identify underlying causes
p Primary cause
p Secondary causes
Basic Causes
p Unsafe Acts ± what activities contributed
to the accident

p Unsafe conditions ± what material


conditions, environmental conditions and
equipment conditions contributed to the
accident
What controls failed?
p G   


    
   
      
   
What controls worked?
p List any controls that prevented a
more serious accident or
minimized collateral damage or
injuries.
Determine
p What was not normal before the
accident
p Where the abnormality occurred
p When it was first noted
p How it occurred.
Change Analysis
p 1. Define the problem (What happened?).
p 2. Establish the norm (What should have
happened?).
p 3. Identify, locate, and describe the change
(What, where, when, to what extent).
p 4. Specify what was and what was not affected.
p 5. Identify the distinctive features of the
change.
p 6. List the possible causes.
p 7. Select the most likely causes.
Report Causes
p Analysis of the Accident ± HOW &
WHY
p a. Direct causes (energy sources;
hazardous materials)
p b. Indirect causes (unsafe acts and
conditions)
p c. Basic causes (management policies;
personal or environmental factors)
Prevention
p What needs to change or be improved to
prevent similar accidents in the future?
À Engineering Controls
À Administrative Controls
À Training Controls
Recommendations
p Action to remedy
À Basic causes
À Indirect causes
À Direct causes
p Recommendations - as a result of the finding is
there a need to make changes to:
À Employee training
À Work Stations Design
À Policies or procedures
Completed Report
p Signed by
investigation
members
p Signed by
injured employee
p ¦orwarded to
claims management
Send & ¦ile Report
p After developing a formal report,
forward it for review & action.

p ¦ile a copy of the report and all raw data,


photos, interview notes, etc. in a single
file
Summary
p Investigate accidents immediately
p Determine who was involved and
who witnessed it
p Ascertain what items or equipment
were involved
p Record detailed description
p Determine causal factors
p Conduct corrective actions
1. It is best to interview witnesses all together in
order to save time. True or ¦alse
2. Name two environmental factors that may be
involved in an accident ________________,
________________.
3. Define a ³minor´ accident according to
investigation procedures:
__________________________________.
4. The main reason for investigating accidents is
to fix the blame somewhere. True or ¦alse
5. Employees need to report injuries only if they
think they need to see a doctor. True or ¦alse
6. Prior to arriving at the accident scene, one
team member should have taken the
__________________.
7. Describe at least 2 factors to investigate about
the injured employee: ______________,
_____________.
8. How could the time of the accident be
considered a causal factor?_______________.
9. Describing the general accident location
is adequate for the report. True or ¦alse
10. Describe at least 2 factors to investigate
when equipment is involved: ____________,
_____________.