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Accident Investigation by ESAO
- 2. 2 Accident Investigation - Objectives By the end of this session the participants will: Understand the importance of the need for effective and thorough investigation of an accident Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner Make meaningful recommendations for preventive actions to reduce potential risks that may contribute to accidents
- 3. 3 Effective Accident Investigations - Objectives (cont.) By the end of this session the participants will: Understand their critical role in the accident investigation and the accident reporting process Determine the cause(s) of this accident and make recommendations to help prevent a recurrence of this type of incident
- 4. 4
- 5. 5 What is an Accident ? “An accident is an undesired event that results in physical harm to a person or damage to property.”
- 6. 6 Purpose of an Accident Investigation The purpose of an accident investigation is to prevent the recurrence of the accident. The focus should be on the accident , not the injury .
- 7. 7 Effective Accident Investigations What to Look for: Policies/Procedures Equipment Materials Environment Task People/Operators Accidents generally have more than one cause
- 8. 8 Critical Injury Defined a) places life in jeopardy; b) produces unconsciousness; c) results in substantial loss of blood; d) involves the fracture of a leg or arm but not a finger or toe; e) involves the amputation of a leg, arm, hand or foot but not a finger or toe; f) consists of burns to a major portion of the body; or g) causes the loss of sight in an eye. O. Reg. 714/82 s.1 For the purpose of the Act and Regulations, “critically injured” means an injury of serious nature that,
- 9. 9 Who Investigates Accidents? They have a personal interest to protect. They know their people, the conditions and the job. They know how to get the information needed. They will take action in any case. Supervisors
- 10. 10 Who Investigates Accidents? JHSC Representative They are familiar with the people and workplace. They have a legal requirement in Critical Injuries They have been trained in Accident Investigation
- 11. 11 Who Investigates Accidents? Government and Business Ministry of Labour Ministry of the Environment Workplace Safety & Insurance Board
- 12. 12 Before an Accident Occurs… Create an accident “action plan” Create an Accident Investigation Policy Develop Investigation Procedures Practice
- 13. 13 When To Investigate An Accident Immediately or ASAP ( If a Critical Injury or Immediately Reportable Accident, secure the scene and advise the MOL ) Accident Investigation Procedures should be in writing to ensure a consistent response to all accidents.
- 14. 14 At the Accident Scene Control the Scene People are the first priority; send for help; make sure area is safe; administer first aid Stop Ongoing Hazards Get personal protective equipment; provide emergency lighting, power, air, etc. Collect Evidence Take notes, pictures, sketches of tools, equipment, layout, etc.
- 15. 15 At the Accident Scene Contributing Factors: Housekeeping Floor/surface conditions Noise Air quality/temperature Equipment malfunction Supervision Employee morale/attitude/health Alcohol/drug abuse
- 16. 16 What Equipment Is Required? Personal Protective Equipment Caution Tape Measuring Tape Graph Paper Pencils Lockout / Tagout Clipboard Camera (battery and film) Flashlight (with batteries) Emergency Phone Numbers Accident Investigation Forms Optional - tape recorder, photo log, flares, etc.
- 17. 17 Immediate Causes Struck By Struck Against Caught In, On, Between, or Under Fall On, In, or From Scraped / Rubbed Against Overexertion or Body Strain Contact with - Electricity - Heat or Cold - Radiation - Noise - Caustics - Toxic Substances
- 18. 18 Basic Causes Lack of preventative maintenance Servicing, Moving or Live Equipment Failure To Warn or Secure Tampering or Removing Safety Devices Unsafe Working or Travelling Speed Unsafe Working Posture or Position Incorrect Equipment or Body Use Poor or Improper Work Practices
- 19. 19 Root Causes Personal Factors Poor Motivation Labour Relations Lack of Skill or Knowledge Physical and/or Psychological Problems Job Factors Poor Purchasing Standards Poor Work Standards Poor Maintenance or Design Abnormal Usage Excessive Wear and Tear Lack of Programs and Procedures
- 20. 20 Equipment or Conditions Involved Equipment Metal Lab cart Specimen Blender Metal work counter electrical appliance plug-ins (cart & counter) metal sink leather shoes eyeglasses Conditions water on floor damaged equipment running water
- 21. 21 Accident Scene • Click here to view accident scene • What happened?
- 22. 22 Flip Chart Layout Who was injured? What happened? How to prevent a recurrence?
- 24. 24 Effective Accident Investigations What to Look for: Policies/Procedures Equipment Materials Environment Task People/Operators Accidents generally have more than one cause
- 25. 25 Accident Investigation Process Response Assess Scene / Identify Witnesses Preserve Evidence Notification Interview Witnesses Analysis and Conclusions Recommendations Follow up
- 26. 26 Accident Investigation Forms Internal Accident Report Investigator’s Checklist Witness Interview Form JHSC Accident Investigation Report Accident Findings Recommendation Form
- 27. 27 At the Accident Scene Contributing Factors: Housekeeping Floor / surface conditions Noise Air quality / temperature Equipment malfunction Supervision Employee morale / attitude / health Alcohol / drug abuse
- 28. 28 Basic Causes Preventative Maintenance Servicing Moving or Live Equipment Failure To Warn or Secure Tampering or Removing Safety Devices Unsafe Working or Travelling Speed Unsafe Working Posture or Position Incorrect Equipment or Body Use Poor or Improper Work Practices
- 29. 29 Root Causes Personal Factors Poor motivation and/or labour relationship Lack of skill or knowledge Physical and/or psychological problems Job Factors Poor purchasing Standards Poor work standards Poor maintenance or design Abnormal usage Excessive wear and tear
- 30. 30 Who Are The Witnesses ? Eye Witness First Person (s) at the scene Witness Surrounding Events Witness Person Having Knowledge
- 31. 31 Interview Process • First - Get The Big Picture • Separate All Witnesses • Interview Each Witness Alone and In Private • Interview Eye Witnesses First • Interview At Accident Scene (when advisable)
- 32. 32 Effective Interview Technique • Put person at ease • Explain purpose of accident investigation • Listen to the individual’s version • Ask the right questions at the right time • Repeat the information given back to the individual • Always thank person for their cooperation • Immediately document critical information • Provide drawings and photos where useful • Probe for Basic Causes • Keep the door open for further information
- 33. 33 Interviewing Questions To Ask • Where were you at the time of the accident ? • What were you doing at the time ? • What did you see, hear ? • What were the environmental conditions ? • What was the injured worker doing at the time ? • In your opinion, what caused the accident ? • How might similar accidents be prevented in the future ?
- 34. 34 Interviewing Questions to Ask • Ask “WHY” 5 times “He was lying on the floor” - Why? “Because there was water on the floor” - Why? “Because there was a leak in the sink” - Why? “Because maintenance hadn’t fixed it” - Why? “Because they’re short-staffed” - Why? “Because of the hiring freeze”
- 35. 35 Typical Investigation • Who was injured? We should clean up spills right away or put sign up saying wet floor. • How to prevent a recurrence? Slipped on spill on floor and struck their head. John Doe • What happened? Hot link to poster 2
- 36. 36 At the Accident Scene • Contributing Factors: Housekeeping Floor/surface conditions Noise Air quality/temperature Equipment malfunction Supervision Employee morale/attitude/health Alcohol/drug abuse
- 37. 37 Investigation Begins • Individual shots of accident scene • Click link(s) • Lab cart - first view • Lab cart - second view • Plug • Water • Feet
- 39. 39 Effective Investigation Poor maintenance / housekeeping Poor labour relations Poor health Tampering / removal of safety device (3 prong & insulating rubber feet Water on floor Contact with live equipment Fall to the floor Struck head Examples… Immediate Causes? Basic Causes? Root Causes?
- 40. 40 Accident Scene Re-visited • Click here to view accident scene • What really happened?
- 41. 41 Recommendations & Follow - Up • Have intermediate control measures been implemented prior to final corrective measure ? • Have the intermediate or final corrective measures resulted in further hazards? • How adequate are the control measures ? • How effective are the control measures ? • Has there been follow-up and an analysis of the corrective measures to ensure they have been implemented and are effective ? •Click to advance to optional Accident Scene
- 42. 42 Thank You
- 45. 45 OFFICE ACCIDENT Contributing Factors: Policies/Procedures Equipment Materials Environment Task People/Operators
- 46. 46 Office Accident Investigation Immediate Causes? Basic Causes? Root Causes?
- 47. 47 Office Accident Investigation Working alone Training Using improper procedure / equipment Standing on cabinet Fall to the floor Struck back Immediate Causes? Basic Causes? Root Causes?
- 48. 48 OFFICE ACCIDENT CONCLUSION Accidents generally have more than one cause Keep asking WHY until you determine the root cause
- 49. 49 Thank You
Editor's Notes
- Put up poster number 1 which only has the chalk marks. This is a TRUE STORY
- Prepare an investigation tool kit as part of the action plan which might include: Camera Tape measure Hard hat Disposable nitrile gloves Safety footwear Writing pad Notebook, etc…
- These same causes of the accident could also, if still present, be a risk for us as well.
- Participants to take a guess as to what happened. They should look at the first poster and identify the items. Reveal afterwards.
- Some of the questions we will need to ask. Have groups try to answer these questions. Give them about 5 to 10 minutes to answer these questions.
- Put up poster number 2, the one with all the photographs.
- Mention that these hazards might still be present
- This exercise is important as the participants will likely jump to conclusions without having full knowledge as they had not interviewed the witnesses.
- Have the 2 witnesses read their accident investigation sheets at the podium. Audience can ask questions of the witnesses. The witnesses can only answer what they know on their sheet. Reveal bullets after the witness statements.
- Participants to add to the list previously made.
- Immediate causes: contact with electricity, fall to floor, struck head Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet) water on floor Root causes: poor maintenance/ housekeeping labour relations poor poor health
- Immediate causes: contact with electricity, fall to floor, struck head Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet) water on floor Root causes: poor maintenance/ housekeeping labour relations poor poor health
- The accident: John Doe was pushing the metal cart. The end of the metal cart hit the plug which was missing a ground pin. The plug was also not all the way into socket at the end of the counter. At that point the metal cart became live. For whatever reason John Doe was not grounded. But as soon as he went to touch the tap he became grounded. The electricity passing through him created a complete circuit so his posture became frozen. He could not move to break the circuit. The supervisor entered the room. She slipped on the floor and kicked the cart which broke the circuit. John Doe then collapsed and struck his head on the ice machine. bump on the head and electrocution killed him. Coroner considered underlying medical condition, seizures, hw would he have survived with this condition. The shoes played no role The water and the condensation from the sink drain were contributing factors Bottom line… The machine on the cart used to have rubberized feet which were no longer there. The plug on the machine no longer had a ground pin as it had been broken off. The receptacle on the cabinet did not have the orange plug inserted all the way. The cart touched the metal contact on the plug which energized it. There was no GFIC present. The electrocution occurred because the worker touched the energized cart and the sink which cause a path to ground through his upper body and his arms.
- Immediate causes: contact with electricity, fall to floor, struck head Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet) water on floor Root causes: poor maintenance/ housekeeping labour relations poor poor health
- Immediate causes: contact with electricity, fall to floor, struck head Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet) water on floor Root causes: poor maintenance/ housekeeping labour relations poor poor health