Accident Investigation Training by Bureau Veritas
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Accident Investigation Training
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Accident Investigation Training by Bureau Veritas
- 2. 2Bureau Veritas Presentation Learning from our Mistakes Accident Investigation
- 3. 3Bureau Veritas Presentation • InstructorInstructor • ScheduleSchedule • ParticipantsParticipants • MaterialsMaterials • ObjectivesObjectives IncidentIncident InvestigationInvestigation Course Introduction Accident Investigation
- 4. 4Bureau Veritas Presentation • Understand the critical importanceUnderstand the critical importance of investigation and reportingof investigation and reporting • Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidentsarrive at the root causes of accidents • Understand the importanceUnderstand the importance of follow-upof follow-up Accident Investigation Course Objectives
- 5. 5Bureau Veritas Presentation • To determine root causes and preventTo determine root causes and prevent recurrence of similar accidentsrecurrence of similar accidents • To demonstrate to employees thatTo demonstrate to employees that management caresmanagement cares Why Investigate? Accident Investigation
- 6. 6Bureau Veritas Presentation EverythingEverything SeriousSerious InjuriesInjuries Minor InjuriesMinor Injuries Non-injury IncidentsNon-injury Incidents ChancesChances 11 2929 300300 350,000350,000 Accident Investigation What to Investigate?
- 7. 7Bureau Veritas Presentation Why don’t employees report everything?Why don’t employees report everything? I saidI said reportreport EVERYTHINGEVERYTHING!!!! Accident Investigation
- 8. 8Bureau Veritas Presentation Resources to find out include:Resources to find out include: • PPeopleeople • AAccident Sceneccident Scene • RRecordsecords ““PAR for the course”PAR for the course” What Happened? Accident Investigation
- 9. 9Bureau Veritas Presentation AccidentAccident ImmediateCausesImmediateCauses BasicCausesBasicCauses SafetySystemSafetySystem Accident Sequence Accident Investigation
- 10. 10Bureau Veritas Presentation The Work SystemThe Work System The EmployeeThe Employee System SystemFailures Failures Basic Basic Causes Causes ImmediateImmediate CausesCauses Causes Accident Investigation
- 11. 11Bureau Veritas Presentation • Case #1 - How do you spell relief?Case #1 - How do you spell relief? • Case #2 – Back to the GrindCase #2 – Back to the Grind Danger - HighDanger - High PressurePressure Workshop Accident Investigation
- 12. 12Bureau Veritas Presentation The ReportThe Report The RepairThe Repair The ReviewThe Review Follow-Up Accident Investigation
- 13. 13Bureau Veritas Presentation •Understand the critical importanceUnderstand the critical importance of investigation and reportingof investigation and reporting • Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidentsarrive at the root causes of accidents • Understand the importanceUnderstand the importance of follow-upof follow-up Summary Accident Investigation
- 14. 14Bureau Veritas Presentation • We investigate to show we care and prevent recurrenceWe investigate to show we care and prevent recurrence • We investigate everything a little to see where we needWe investigate everything a little to see where we need to investigate a lotto investigate a lot • We use people, the accident scene and records (PAR) toWe use people, the accident scene and records (PAR) to find out what happenedfind out what happened • We use the Accident Analysis Flow Chart and ask “Why”We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’sto help find out why the accident occurred and realize it’s almost always rooted in the management systemalmost always rooted in the management system • We report, repair and review to make sure that the actionsWe report, repair and review to make sure that the actions necessary to prevent recurrence are completednecessary to prevent recurrence are completed Summary Accident Investigation
- 15. 15Bureau Veritas Presentation ClosingClosing Accident Investigation
Editor's Notes
- Introduce self ( position, experience) Cover course schedule Have the participants introduce themselves to instructor and each other (At this point the instructor can do a very short icebreaker if desired) Distribute and cover briefly the materials and how they will be used Mention will cover objectives in next slide.
- Emphasize importance that company places on the process Mention will give participants tools to use to assist them in finding the real causes of accidents and will talk about this more in a minute Mention that many good accident investigations fail because the actions to prevent recurrence are never properly implemented
- Ask the participants why accidents should be investigated. Write their responses on a flip chart and briefly discuss each. Then show the slide and compare. Describe what a “root cause” is. For each of the bulleted items, ask the participants why this is important. Lead the discussion to uncover items such as: Creates trust in the work environment Puts flesh on the bones of safety commitment Helps eliminate unnecessary costs (safety, productivity, quality, etc.)
- Although we investigate “everything”, we spend the most time on the ones that could or did result in serious injury or damage. Describe each level of the iceberg and how the number of events at each level rises geometrically. Explain how, if the severity potential is present, any at-risk behavior, non-injury accident or minor injury could have been a serious injury. The only difference is chance, or luck. Underscore how we need to report and investigate everything so we can see which events need further attention. Ask participants are they getting all of these events reported.
- Divide the participants into groups of 4-6 (quickly). Ask the groups to take 2-3 minutes and come up with the top three reasons employees don’t report accidents and near accidents (sometimes referred to as near misses). After the time is up, take about 5 minutes to ask the groups one-at-a-time to give you one of their reasons. Write them on a flip chart. Continue taking/writing reasons until there are no new ones or time is up. If the client has allowed adequate time, have each group address one of the reasons and come up with some ideas to address it. Have each group present their ideas. If time is short, tell the participants they can do some “homework” after you leave by coming up with a plan to address the top two or three reasons.
- Tell participants that finding out what happened has to precede finding out why it happened, and that is our ultimate goal. Here are three resources to help us find out what happened - the acronym is PAR. Finding out what happened is “PAR” for this course! People - who were the witnesses, who has knowledge of how the process involved works, who trains people to do the job, who maintains the equipment, who designed it and/or purchased it, etc. Accident Scene - what is there that shouldn’t be; what isn’t there that should be; what is the placement of key parts, switches, equipment; what chemicals are used in the area; etc. Records - production records, inspections, reports, maintenance records, training records, purchase orders, warranties, invoices, logs, etc. Now you can write a clear, meaningful accident description. This will be your ticket to discovering the “why” of the accident.
- Accidents are rarely, if ever, the result of a single cause. They almost almost always start out in time and space far removed from the actual time and place of the accident. The accident is what happens last in the sequence, so we are really going backwards. The accidents results from immediate causes. Immediate Causes (causes usually close to the accident in time and space), such as working without a guard, defective equipment, etc. Immediate Causes are like the symptoms of a disease. If you treat the symptoms, the disease seems to get better for a little while, then comes back with a vengeance! Basic Causes (reasons the immediate causes existed), such as poor design, inadequate maintenance, or trying to save time. Basic Causes are like the disease. Failures in the safety system (standards, procedures, programs, enforcement, training - all reasons the basic causes existed).
- Have participants refer to the Accident Cause Analysis Flow Chart in their handout on page XX. Go over briefly the columns. Ask the question, which of the columns does the employee have direct control over? Types is basically the types of energy in the facility - employee control? Results are accident severity, determined by the amount of energy in the system - under employee control? Immediate Causes are usually due to some action of an employee Basic Causes - employee control? Safety System - employee control? So where does most of the responsibility lie for controlling accidents?
- Case #1 - Have the participants review the case in their groups, then do the following: Using the “PAR” system, help them identify where they are going to get information (for example, under People, they might want to talk to the injured employee, the area supervisor, the maintenance man, the maintenance supervisor, etc. Under Accident Scene, they may want to review the piping layout, the types of material the pipe is made of, what contaminants might get into the steam, etc. Under records, they might want to review maintenance records, valve design specifications, etc. Help them make a list of accident causes. Using the Accident Analysis Flowchart, help them classify each of the causes as an Immediate Cause, a Basic Cause, or a Safety System Failure. When you don’t know the Basic Causes or Safety System Failures, just begin to ask, “WHY”, for each Immediate Cause. By the time you ask why 4-5 times deep, you have arrived at the Basic Causes and System Failures. Case #2 - Have the groups go through the same process with this case by themselves. After 10 minutes, record their findings on a flip chart.
- A gentleman once said, “You’d best use the information you get from accident investigations. After all, somebody got hurt to get it for you.” Three important things are necessary for an investigation to go anywhere. The Report - We all love to do paperwork. It is absolutely essential we record our findings on the appropriate forms. The report should include descriptions with everything you found out in your PAR, causes (immediate, basic and system), and what is going to be done short term and long term to correct the causes. Sometimes approval must be obtained from higher management for these recommendations. The Repair - Many times I have seen good investigations become useless because the actions that needed to be taken were never implemented, or, were implemented poorly. The Review - Someone needs to follow-up to be sure that the actions recommended were implemented and that they were effective in controlling the exposures that produced the losses. You can do this. Just keep a copy of the report in your “tickler” file until all actions are complete. Ask participants if they have ever used a formal tracking system for action items. If so, have them describe it. Ask participants what types of corrective actions they would suggest for the Case of “Back to the Grind”.
- Ask the participants to tell you what they learned about each of the items on the slide.
- During one of the first Continental Congresses, two famous men were present. One was General Alexander Smythe. The other was representative Henry Clay. General Smythe was known for his long, tedious, laborious speeches. After one particularly onerous speech, General Smythe turned to Henry Clay and said, “You sir, speak for the present generation. I, on the other hand, speak for posterity,” to which Henry Clay promptly replied, “Yes, and you seem determined to speak until the arrival of your audience!” I hope that is not how you have felt about my presentation today. I thank you for your time and attention!