A Part 21 Accident Investigation


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Accident investigation, Health and Safety Course

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A Part 21 Accident Investigation

  1. 1. ACCIDENTS Causation, Reporting & Investigation
  2. 2. Causation Theories Single Cause Domino Theory  Multiple Causation 
  3. 3. Single Cause Domino Theory Heinrich’s theory  Each factor is the fault of the factor that  immediately precedes it A preventable injury is the natural culmination of  a series of events or circumstances, which occur in a fixed logical order
  4. 4. Single Cause Domino Theory Ancestry & Social Fault of Person Unsafe Act or Accident Injury Environment Condition
  5. 5. Single Cause Domino Theory If one of the dominoes is removed then the  chain of events will be halted, and the accident will not happen Element 3 (unsafe act and/or mechanical or  physical hazard) is probably the easiest factor to remove
  6. 6. Single Cause Domino Theory Bird & Loftus extended Heinrich’s theory to encompass the  influence of management in the cause & effect of accidents They suggested a modified sequence as follows:  Lack of management control, permitting  Basic causes (personal & job factors), leading to  Immediate causes (substandard practices or conditions), which are the  direct cause of The accident, which results in  Loss (negligible, minor, serious or catastrophic  This modified sequence can be applied to every accident and is  of basic importance to loss control management
  7. 7. Multiple Causation May be more than one cause, not only in  sequence, but occurring at the same time In accident investigation all causes must be  identified Usually simple accidents have a single cause  Major disasters normally have multiple causes 
  8. 8. Multiple Causation Cause a Cause b Unsafe Act Cause c Injury or Accident Damage Cause d Unsafe Cause e Condition Cause f
  9. 9. Unsafe Acts Categories:  Operating without clearance  Operating at unsafe speed  Rendering safety devices inoperative  Using unsafe equipment, or using it unsafely  Unsafe methods e.g. loading, carrying, mixing  Adopting unsafe position or posture  Working on moving or dangerous equipment  Horseplay e.g. distracting, teasing, startling  Failure to wear PPE  Lack of concentration; fatigue or ill health  Human Factors 
  10. 10. Unsafe Acts Unsafe acts can be active or passive:   Active Unsafe Acts:  Worker deliberately removes machine guard  Passive Unsafe Acts:  More difficult to deal with  By pursuing an active safety policy, it is possible to achieve a reduction in bad habits and hence accidents
  11. 11. Unsafe Conditions Categories:  Inadequate guarding  Unguarded machinery  Defective, rough, sharp, slippery, decayed, cracked surfaces  Unsafely designed equipment  Poor housekeeping, congestion  Inadequate lighting, glare, reflections  Inadequate ventilation, contaminated air  Unsafe clothing or PPE  Unsafe processes  Hot, humid or noisy environment 
  12. 12. Unsafe Acts/Conditions The picture shows how unsafe acts & conditions may interact to produce an  accident. Accident potential is increased when unsafe acts & conditions occur simultaneously. Of course, this is not to say that an act or condition alone could not result in an accident. Potential Accident Unsafe Acts Unsafe Conditions
  13. 13. Accident Reporting Information should be kept for all injuries, and  preferably for near misses The safety practitioner needs to design a  suitable form to ensure that he gets the information that he needs for investigations
  14. 14. Accident Investigation Records Format:  Name & personal details of victim  Date, day and time of accident  Location of accident  Occupation of victim  Job being done at time  Nature of injury or damage  What inflicted the injury or damage  Who had control of the cause of the injury or damage  What actually happened  Basic and immediate causes  Immediate remedial action taken  Recommendations to prevent recurrence 
  15. 15. Use of Investigation Records Accident records are useless if they are used only to count accidents.  Detailed and thorough study of the records as part of the normal ongoing accident prevention programme should yield the following useful information: Relative importance of the various injury & damage sources  Conditions, processes, machines and activities which cause the  injuries/damage The extent of repetition of each type of injury or accident in each  operation Accident repeaters, I.e. those workers who tend to be repeatedly injured  or are involved in more accidents How to prevent similar accidents in future 
  16. 16. Accident Investigation Could be carried out by:  Safety Practitioner  Management or Supervisor  Safety Representative  Inspector  A joint investigation by company/safety rep is often a good idea  An investigation which does not discover what went wrong, and  produce some useful information and recommendations for corrective action, is just a waste of time
  17. 17. Accident Investigation Initial Actions  Questioning the victim  Treatment of victim is first priority  Immediate questioning may not be possible - they should be allowed to  collect their thoughts and control their nerves Witnesses & Conditions  Investigator can usually go to accident scene and get a fairly complete  story from on-site conditions and witnesses In all serious accidents and in all other cases where practicable,  conditions at accident scene should remain undisturbed until investigation is complete
  18. 18. Investigators Immediate supervisor:   Likelyto know most about the situation  Knows his own people better than anyone  Has personal interest in determining causes, as accidents affect the efficiency and morale of his department  Familiarity with staff could cause problems
  19. 19. Investigators Recognising Hazards  Familiarity with plant, equipment and layout of operations will assist  in recognising hazards that have been overlooked for some time Unsafe acts, as well as conditions, contribute towards most  accidents It is not sufficient merely to recommend fitting a guard while  overlooking the unsafe act, such as rendering the guard ineffective or placing hands in the danger zone It is also insufficient to limit attention to an unsafe act if fitting a  better guard would reduce the likelihood of injury
  20. 20. Investigators Safety Practitioner   Necessary in more serious cases  Supervisor may not have necessary authority  Should seek assistance from local supervisor  Investigator must have authority to go as far as is necessary to get to the cause of the problem
  21. 21. The Investigation Promptness  As soon as possible after the event   Facts will be easier to determine and more details will be remembered by those involved Fire  Helpful if investigator is present during the fire   Investigator may gain useful information by watching the activities of firemen
  22. 22. The Investigation Evidence   Depending on severity of any injuries or damage, investigator should be present during clear-up and reinstatement as valuable clues may otherwise be missed  Failing which, supervisor should take it upon himself to collect the necessary evidence
  23. 23. The Investigation Equipment  Photographic equipment  Portable lights (electricity may be switched off or accident scene may be  poorly lit) Sketchpad, pencils and measuring equipment  Record-keeping equipment e.g. notebook and cassette recorder  Sample collection equipment e.g. jars, paper bags, cartons etc.  Tools for cleaning debris or spillages should also be available  Portable gas/vapour detecting equipment 
  24. 24. Accident Investigation Procedure 1. Inspection of the accident scene to collect any information relating to physical conditions of the plant, equipment and building 2. Interview witnesses and others likely to give information concerning any unsafe acts or conditions which may have contributed to the accident 3. Summarise all available evidence accurately in a written report to management, recommending future actions to prevent a recurrence
  25. 25. Inspection of the Scene Careful, detailed look at accident scene, evaluating and noting  the following:  Extent & severity of damage  Damage to surrounding property  Environmental conditions which may have had some bearing on the accident, such as temperature, ventilation, humidity and illumination Survey the accident scene to see if there are any obvious  dangerous physical conditions which may have been responsible for the accident
  26. 26. Inspection of the Scene In the case of spillages, splashes or other escapes of  poisonous, explosive, flammable or other dangerous material, it may be necessary to take samples for subsequent investigation Where machinery or other equipment has been involved, it may  be necessary to issue instructions prohibiting the use or repair of it until the investigation has been completed
  27. 27. Talking with On-Site Personnel Easy to upset people when asking questions about what has  been done, or what has not been done Casual remarks made during the site inspection may be quite  revealing and the investigator should continue to talk to any personnel involved near the scene of the accident This would also serve as an ideal opportunity to explain the  object of the exercise is to discover and root out the causes so as to prevent a repetition. It is not to apportion blame or to criticise any individual
  28. 28. Interviewing Witnesses Types of Witness  Primary witness  The victim  Secondary witness  Extremely rare, the eyewitness  How many people really see the instant of an accident?  Tertiary witness  Can offer variety of corroborative statements regarding the acts of  people or environmental
  29. 29. Interviewing Witnesses Putting witnesses at ease  Explain fully purpose of investigation   Encourage participation and involvement  Show interest in any ideas they might have about possible preventive measures  Witness must be assured that the purpose of the investigation is not to blame anyone, but to attempt to find out the cause and thereby reduce possibility of a recurrence
  30. 30. Interviewing Witnesses Interview Location  Best to carry out interviews at scene of accident, as it  is easier for those involved to communicate effectively with “props” close to hand  Easier to explain what happened if witnesses are able to point out specific things and recall their actions related to specific locations
  31. 31. Interviewing Witnesses Question Phrasing  Open ended question - what, where, when, how or who   Questions starting with why may put witness on the defensive  Typical questions: What happened? What did you see?What time was it?  Where were you at the time? Where was the victim?  When did you realise something was wrong?  How did it happen? How were you involved?  How could it have been prevented?  Who else was involved? Who else saw it? Who reported it? 
  32. 32. Interviewing Witnesses Attitude  “What happened” will often promote the fullest response and it is vital the  investigator listens, without interruption, to the witness’s account of the accident If something is not understood, investigator should wait until witness has  completed his account before asking for clarification Do not disagree with any of witness’s statement or make any judgements  on his evidence alone What a witness believes to have happened will depend to some extent on  just how he perceived the situation, even though this might conflict with the actual facts
  33. 33. Interviewing Witnesses Conclusion  When witness’s account of accident has been heard,  investigator should repeat it to witness to ensure account is fully understood  Interview should be concluded on a positive note, which is best achieved by discussing any ideas he may have regarding prevention of a similar occurrence - this will serve to reaffirm the purpose of the interview and ensure the witness’s further co-operation, should it be needed
  34. 34. Interviewing the Victim Ideally first to be interviewed  Injuries may be serious, or may be suffering  from shock Should be interviewed at the earliest  opportunity General principles for interviewing witnesses  apply
  35. 35. What Should be Investigated ALL incidents/accidents should be investigated  Purpose is to find the cause, with the intention  of preventing a recurrence, rather than apportioning blame An injury usually involves some degree of blame  falling on management, supervision, victim or workers
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