EXPLORING ROOT CAUSE ACCIDENT INVESTIGATION
What is an Accident? <ul><li>An unintended happening, mishap. </li></ul><ul><li>Most often, an accident is any unplanned e...
3 Basic Types of Accidents: <ul><li>Minor Accidents such as paper cuts or fingers or dropping a box of materials. </li></u...
 
Why Determine Root Cause <ul><li>Will determine how and why of failures. </li></ul><ul><li>Examine possible corrective act...
How To Establish Root Cause <ul><li>When investigating, keep the real purpose in mind – ROOT CAUSE. </li></ul><ul><li>Focu...
When Searching For Root Cause: <ul><li>The investigator must search for the cause and effect chain of events that lead to ...
Searching for Root Causes: <ul><li>Dig deep for the root causes (think like a tree root system). </li></ul><ul><li>A succe...
Accident Investigation Questions <ul><li>Who was injured? </li></ul><ul><li>Who witnessed the accident? </li></ul><ul><li>...
Accident Investigation Qustions <ul><li>7. When did accident occur? </li></ul><ul><li>When was medical treatment requested...
Interviewing <ul><li>Let each witness speak freely and take notes without distracting the witness (use a tape recorder onl...
Interviewing <ul><li>Excellent source of first hand knowledge. </li></ul><ul><li>May present pitfalls in the form of: </li...
Interviewing <ul><li>Get preliminary statements as soon as possible from all witnesses. </li></ul><ul><li>Locate the posit...
Interviewing <ul><li>Word each question carefully and be sure the witness understands.  </li></ul><ul><li>Identify the qua...
Record the Facts <ul><li>Interview witnesses as soon as possible. </li></ul><ul><li>Document the accident scene before any...
Record the Facts <ul><li>Keep all notes and remarks in a bound notebook or three ring binder. </li></ul><ul><li>Record: </...
Record the Facts <ul><li>Even the most insignificant detail may be useful. </li></ul><ul><li>Document and then document so...
Problem Solving Techniques Change Analysis <ul><li>This technique emphasizes change to correct the problem. </li></ul><ul>...
Problem Solving Techniques Change Analysis <ul><li>Use the following steps in this method: </li></ul><ul><ul><li>Define th...
Problem Solving Techniques Job Safety Analysis <ul><li>Job safety analysis (JSA) is part of many existing accident prevent...
Problem Solving Techniques Job Safety Analysis
BENEFITS OF ACCIDENT INVESTIGATION – ROOT CAUSE ANALISYS <ul><li>PREVENTING RECURRENCE </li></ul><ul><li>IDENTIFYING OUT-M...
BENEFITS OF ACCIDENT INVESTIGATION – ROOT CAUSE ANALYSIS <ul><li>WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCI...
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Accidentrootcauseinvestigationpresentation

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

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