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  • This presentation is very useful in both on board ships and ashore in general in preventing accidents and keeping in mind the importance of safety at all times without fail.
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    Accidentrootcauseinvestigationpresentation Accidentrootcauseinvestigationpresentation Presentation Transcript

    • EXPLORING ROOT CAUSE ACCIDENT INVESTIGATION
    • What is an Accident?
      • An unintended happening, mishap.
      • Most often, an accident is any unplanned event that results in personal injury or property damage.
      • The failure of people, equipment, supplies or surroundings to behave or react as expected causes most accidents.
    • 3 Basic Types of Accidents:
      • Minor Accidents such as paper cuts or fingers or dropping a box of materials.
      • Serious Accident such as incidents that cause injury or damage to equipment or property. For instance a forklift dropping a load or someone falling off a ladder.
      • Accidents that occur over an extended time period such as hearing loss or illness resulting for chemicals
    •  
    • Why Determine Root Cause
      • Will determine how and why of failures.
      • Examine possible corrective action.
      • Aid in the accident prevention and elimination of a clearly identified hazard.
      • Investigation is not intended to place blame.
    • How To Establish Root Cause
      • When investigating, keep the real purpose in mind – ROOT CAUSE.
      • Focus on improving the system, not punishing the worker.
      • This requires extensive exploring into all factors of the incident.
    • When Searching For Root Cause:
      • The investigator must search for the cause and effect chain of events that lead to the accident.
      • Keep in mind the effect is the accident.
      • The investigator should work backwards from the incident, which if worked backwards long enough will reveal the root cause.
    • Searching for Root Causes:
      • Dig deep for the root causes (think like a tree root system).
      • A successful root cause analysis will ask the question “why” no less than five times.
      • Patience is the key, keep asking why until the root cause becomes apparent.
      • Always praise employees for their help.
    • Accident Investigation Questions
      • Who was injured?
      • Who witnessed the accident?
      • Who did not witness the accident?
      • What was the injured doing just prior to the accident?
      • What equipment was he/she using?
      • What were the weather, lighting surface conditions?
    • Accident Investigation Qustions
      • 7. When did accident occur?
      • When was medical treatment requested?
      • When did medical personnel arrive?
      • Why did it occur?
    • Interviewing
      • Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness).
      • Use sketches and diagrams to help the witness.
      • Emphasize areas of direct observation and label hearsay accordingly.
      • Record the exact words used by the witness to describe each observation.
    • Interviewing
      • Excellent source of first hand knowledge.
      • May present pitfalls in the form of:
        • Bias
        • Perspective
        • Embellishment
      • It is important to maintain a clear thought process and control of the interview.
    • Interviewing
      • Get preliminary statements as soon as possible from all witnesses.
      • Locate the position of each witness on a master chart (including the direction of view)
      • Explain the purpose of the investigation (accident prevention) and put each witness at ease.
    • Interviewing
      • Word each question carefully and be sure the witness understands.
      • Identify the qualifications of each witness (name, address, occupation, years of experience, etc.).
      • Supply each witness with a copy of their statements (signed statements are desirable).
    • Record the Facts
      • Interview witnesses as soon as possible.
      • Document the accident scene before any changes are made.
        • Take photos
        • Draw scaled sketches
        • Record measurements
      • Gather support documents such as maintenance records, reports, production schedules or process diagrams.
    • Record the Facts
      • Keep all notes and remarks in a bound notebook or three ring binder.
      • Record:
        • Pre-accident conditions
        • Accident sequence
        • Post-accident conditions
      • Document victim location, witnesses, machinery, energy sources and other contributing factors.
    • Record the Facts
      • Even the most insignificant detail may be useful.
      • Document and then document some more.
      • The investigator should be concentrating solely on the investigation at hand.
    • Problem Solving Techniques Change Analysis
      • This technique emphasizes change to correct the problem.
      • Examination of deviations from the norm are scrutinized.
      • Consider all problems to result from some unanticipated change.
      • Analyze the changes to determine its cause.
    • Problem Solving Techniques Change Analysis
      • Use the following steps in this method:
        • Define the problem (What happened?).
        • Establish the norm (What should have happened?).
        • Identify, locate, and describe the change (What, where, when, to what extent).
        • Specify what was and what was not affected.
        • Identify the distinctive features of the change.
        • List the possible causes.
        • Select the most likely causes.
    • Problem Solving Techniques Job Safety Analysis
      • Job safety analysis (JSA) is part of many existing accident prevention programs.
      • In general, JSA breaks a job into basic steps, and identifies the hazards associated with each step as well as prescribing controls for each hazard.
      • A JSA is a chart listing these steps, hazards, and controls.
      • Review the JSA during the investigation if a JSA has been conducted for the job involved in an accident.
      • Perform a JSA if one is not available to determine the events and conditions that led to the accident.
    • Problem Solving Techniques Job Safety Analysis
    • BENEFITS OF ACCIDENT INVESTIGATION – ROOT CAUSE ANALISYS
      • PREVENTING RECURRENCE
      • IDENTIFYING OUT-MODED PROCEDURES
      • IMPROVEMENTS TO WORK ENVIRONMENT
    • BENEFITS OF ACCIDENT INVESTIGATION – ROOT CAUSE ANALYSIS
      • WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELL-BEING OF ITS EMPLOYEES