HSE - Accident Investigation.PPT

1. To appreciate the relevance of accident investigation
2. To understand the process of accident investigation
3. To recognize the components of accident
investigation
4. To gain knowledge on some techniques in root cause
identification
5. To be guided with the legal implication of an accident
Topic Objectives:
ACCIDENT INVESTIGATION

Definition of Terms

To prevent it from reoccurring.
To determine whether safety procedures,
practices and/or training should be modified.
To identify areas for improvement and track
safety performance trends.
To correct near misses before they become
accidents.
To demonstrates management’s commitment
to safety.
Why do we do Accident Investigations (AI)?
Definition of Terms

Important Terms: The event
Accident - An event or situation that
has caused injury, illness,
loss of lives, property
damage/loss, or shutdown.
Near Miss - An incident or event in
which an injury or property
loss was narrowly avoided.
Definition of Terms

Elements of Accident
1. Personal injury or illness
2. Property damage
3. Combination of items 1 & 2
Definition of Terms

Important Terms: Types of Accidents
First Aid Case (FAC) - Any one time treatment
and subsequent observation
of minor work-related injuries
which do not ordinarily require
medical care.
Lost Day Case (LDC) - Case which involves
days away from work or days
of restricted work activity. The
start of a Lost Day Case does
not include the day of injury.
Definition of Terms

Important Terms: Types of Incidents
Illness (recordable)- Any abnormal condition or disorder
developed over time caused by exposure to
environmental factors associated with
employment. Includes acute or chronic
disease or illnesses caused by inhalation,
absorption, ingestion, or direct contact.
Injury (recordable) - Any bodily damage (cut requiring sutures,
fracture, sprain, amputation, etc.) which
resulted from a near-miss/ incident or from a
single instantaneous exposure at the work
environment.
Definition of Terms

Important Notes: Results from Accidents
Any event during work which
resulted in:
 an injury/illness requiring loss
of time from work
 medical treatment beyond first
aid, prescription medications
 modifications of an employee’s
regular duties
Definition of Terms

Important Terms: Lost Workdays
Lost Workdays- Away from Work
- The number of workdays an employee
would have worked but could not, due to
occupational injury or illness.
Lost Workdays-Restricted Work Activity
- The number of days an employee was
assigned to another job temporarily,
worked at a permanent job less than full
time, or worked a permanently assigned
job but could not perform all normal
duties associated with it, due to
occupational injury or illness.
Definition of Terms

Accident Report
The report form to be completed by the manager or
supervisor of any injured employee. It contains:
a description of the injury/incident
causes of the injury/incident
 corrective actions to prevent reoccurrence of
the same incident/injury (these may sometimes
be part of a separate document)
SIR
Important Terms: Reports
Definition of Terms

OVERVIEW

What is Accident Investigation (AI)?
 respond immediately to an
injury/incident
 gathering and documenting facts
 identifying/assembling an Investigation
Team
 analyzing root cause
 following-up with corrective actions, to
prevent a reoccurrence
?
A careful analysis of the causes of the accidents
considering various factors. It is a process that:
Overview

Objective of AI
Objective: “Fact finding not Fault
finding”
Overview

What to Investigate?
1. Design
2. Environment
condition
3. Behavior
Overview

Guidelines in AI
1. investigate immediately
2. ensure immediate treatment
3. secure the area
4. record details of event (photo, sketch, etc.)
5. collect physical evidence
6. review other source (victim’s record, friends, etc.)
7. interview witness (5Ws + 1H)
8. write causal factors (eqpt., personnel, materials, procedure)
9. make recommendations (effective/reliable results &
efficient/resources)
Overview

 Immediately investigate all accidents
and incidents to emphasize it as a
priority.
 Take immediate action to correct
deficiencies by assigning and
monitoring corrective actions.
 Complete and distribute the accident
report.
 Report back to employees with findings
and corrective actions as appropriate.
Role of the Supervisor/Manager
Overview

 Require employees to report to
Health Services for medical
treatment for evaluation.
 Secure any conditions that could
lead to further injury or property
damage.
 Notify appropriate people per
your site’s procedures.
Responsibilities During an Accident
Overview

 Initiate and coordinate the investigation by collecting all
materials and information from the employee and
witnesses.
 Document the investigation by completing all required
data on the accident report form within a 24-hour
period.
 Document and establish actions (safety policy,
standards, procedures) required to prevent recurrence.
Responsibilities after the Accident
The supervisor/manager shall:
Overview

Please keep the following points in mind :
 Employees with access to health information and
medical records have a professional obligation to
keep this information strictly confidential for the
protection of the privacy of the individual.
 Medical record information must be made not
available to individuals outside the company
without their expressed written permission.
 Employee names and World Wide ID numbers
should NOT be included on any form which may
include medical record information.
Responsibility for Confidentiality
Overview

First, ensure that the injured receive prompt
medical treatment.
 For severe injuries notify site Emergency
Response Team (ERT) immediately, which
will activate emergency response
procedures.
 For minor injuries, direct or escort the injured
to the site health services.
Steps for Responding to an Accident
Overview

Second, ensure that the appropriate personnel
secure the area to prevent further injury and
maintain facts and conditions surrounding
the accident.
Third, notify appropriate people as outline in
you sites Accident Investigation Procedure.
Steps for Responding to an Accident
Overview

 Security or ERT will secure the area
in the case of a severe injury.
 In case of 3 or more injured, the
scene will remain secure until
released by the site Safety Officer.
 In all cases the scene shall not be
disturbed unless necessary to
eliminate a hazard.
Steps for Responding to a Severe
Accident
ERT
Overview

 The size and make-up of the team is determined by the
seriousness or complexity of the accident.
 This team may include a Safety Engineer, a Process
Engineer, a Maintenance or Electrical Engineer and any
other experts needed for a thorough investigation.
 The investigation will require a review by the Legal
Department and Risk Management.
Identify/Assemble the
Investigation Team
Overview

General Process Flow of AI
Secure
the area &
assign
inv. team
Document
the facts:
hard
evidence,
witness
Ensure
immediate
medical
treatment
Gather
facts
about the
accident:
witnesses
Identify
the root
cause
(causal
factors)
Corrective
action
Overview

GATHERING OF FACTS

Gathering the Facts: At the Scene
 Begin immediately before the evidence at the
scene is disturbed.
 Determine what physical evidence needs to be
preserved and be liberal in collecting it.
 Determine if an expert needs to assist in
collecting evidence.
 Take samples of unknown chemical spills, vapors,
residues, dust, etc.
 Take photographs/video and draw diagrams or
sketches prior to restoring the scene.
Gathering of Facts

Gathering the Facts: At the Scene
Examples of what you would record:
 The condition of the working surface.
 The position of valves, switches,
equipment, vehicles, tools, etc.
 The general level of lighting, lights not
working, etc.
 Any other unsafe conditions that may
have contributed to the accident.
Gathering of Facts

Gathering the Facts: Interviewing
People
 Begin interviewing as soon as possible.
 Identify people involved in the accident and
eyewitnesses that saw anything before, during and after.
 Identify others who may be expert sources of useful
information.
 Interview witnesses individually and in private so that
their comments are not influenced by others.
 Keep witnesses separate from each other.
Gathering of Facts

Gathering the Facts: Other Resources
Examples of other resources :
 original design drawings
 design specifications
 incident/accident reports
 equipment maintenance records
 industrial hygiene monitoring records
 training records
 Safety Data Sheets (SDS), operating and PM specs
Gathering of Facts

Interviewing Skills
Good interviewing skills
involve both
Questioning and
Listening.
Gathering of Facts

EXERCISE EYE CONTACT

There are five steps to an interview:
 Preparation
 Opening
 Questioning
 Feedback
 Closing
Interviewing Skills
Gathering of Facts

Documenting the Facts
After the interview, divide the collected data into
categories:
 Hard Evidence - Data that usually cannot be
disputed, such as the time and place of the
accident.
 Witness Statements - From people who saw
the event and those who came on the scene
immediately following the accident.
 Circumstantial Evidence - Logical
interpretation of facts that lead to a single, but
unproved conclusion.
Gathering of Facts

Review all the data and write a summary of the
accident. The summary should include:
 A detailed, sequential order of the events
and conditions that lead to the accident.
 Clarifying information, such as positions of
people or location of equipment (if it
contributed to the accident).
 Opinions and inferences that are important,
but note the information as such.
Documenting the Facts
Gathering of Facts

For minor injuries or minor property
damage, the supervisor/manager,
with the assistance of employees
involved, usually investigates the
accident.
The Investigation Team
Gathering of Facts

Follow-up to Accident Investigation
 Supervisors and investigating managers own the follow-up
of corrective action in an AI.
 This AI progress should be tracked.
 Completion dates and what was corrected must be
STANDARDIZED.
 AI progress should be communicated to the staff as soon as
possible, to prevent further occurrences.
 Results of completed AI should be published and sent to
those who must received copies.
 It could become critical at a later time to have a record
showing that Corrective Action were completed.
Gathering of Facts

ACCIDENT REPORTING

Results of an investigation should be
communicated to:
 the affected work group
 Safety Committee
 any other person who would benefit from
knowing the details
Communicating the Results of
your Investigation
Accident Reporting

Questions in AI
Questions for reporting: WHO
- was injured?
- saw the accident?
- was working with the injured?
- had instructed/assigned the job to the injured?
- else was involved?
- has the information of events prior to the
accidents?
Accident Reporting

Questions for reporting: WHAT
- is the injury?
- is the damage or loss?
- was the injured doing?
- had the injured been
instructed to do?
- tools/equipment/machinery
were being used?
- did the injured & any
witnesses saw?
- training had been given?
- were the contributory
causes of the accident?
- communication system
was used?
- state of health of the
injured?
- safety rules were
violated?
- safety system and
procedures were there?
Questions in AI
Accident Reporting

Questions for reporting: WHEN
- did the accident occur?
- did the damage become evident?
- did the injured start the job?
- was the explanation of hazard given?
- did the supervisor last see the injured?
- did the persons involved last have food & rest?
Questions in AI
Accident Reporting

Questions for reporting: WHY
- did the injury occur?
- did the communication
fail?
- was the training not
given?
- were the unsafe condition
permitted?
- was the hazard not
spotted at previous
inspection?
- was PPE not provided?
- was PPE not used?
- was there no safe system
of work?
- no safety instruction
given?
- was the supervisor not
consulted when things
started go wrong?
- was the supervisor not
there at the time?
Questions in AI
Accident Reporting

Questions for reporting: WHERE
- did the accident occur?
- did the damage occur?
- was the supervisor at that time?
- was the witnesses at that time?
Questions in AI
Accident Reporting

Questions for reporting: HOW
- did the injury occur?
- could the accident have been avoided?
- could have been the injury avoided?
- could the supervisor have prevented the
accident?
- could better design help?
Questions in AI
Accident Reporting

 Inform employees of their responsibility to
report accidents and hazardous conditions.
 Remind employees of the consequences of
NOT reporting accidents promptly:
 Injury may become worse without
prompt medical attention.
 Similar or same injury may occur to
another employee.
 Lost productivity is magnified.
Ways to Encourage Reporting Accidents
Accident Reporting

 a complete description of the accident and equipment and
materials involved
 a complete description of unsafe acts/behaviors or
conditions directly contributing to the accident
 any underlying reasons for unsafe behaviors or conditions
 contributing factors to the accident
What information is needed on the
accident investigation form?
 identification of the root cause
 specific corrective actions to prevent reoccurrence
 individual’s responsible for accident reporting
 completion date accident report Accident Reporting

ROOT CAUSES

A Root Cause is the primary
cause or causes of an
accident that, when identified
accurately and corrected, will
prevent reoccurrence.
What is a Root Cause?
Root Causes

Analyze investigation results to uncover Root Cause.
 Categorize your notes (job experience, location, site
layout, work practices, etc.).
 Analyze interview information.
 Re-interview if necessary.
 Review equipment and operation specs, and safety
documents.
How do you identify Root Cause(s)?
Root Causes

Use a systematic problem solving approach to
identify the following:
 amount and quality of job training
 type and frequency of job supervision
 Was motivation/disciplinary procedures were
effective in promoting safety rules and procedures?
 history of prior accidents or near-misses with a
piece of equipment or procedures involved
 were procedures followed? (and if not, why not?)
How do you Identify Root Cause?
Root Causes

Tools for Identifying Root Cause
 7 Step Problem-Solving
Methodology
 Root Cause Analysis Tree
 Guide for Identifying Causal Factors
and Corrective Actions
Root Causes

7-Step Problem-Solving Methodology
 Identify the problems.
 Prioritize the problem.
 Perform a cause analysis.
 Generate solutions.
 Present solutions for approval
 Implement and check results.
 Standardize new solutions.
Root Causes

Management Manpower Mother Nature
Machine Method Material
Frequent
scaffold
accident
Low Performance
Insufficient
number of tools
Lack of
control system
Wrong Sequence
Poor supervision
Bad attitude
Poor working condition
Lack of
testing
apparatus
Incorrect
Material
Material Damaged
Skills problem
Temp
Lack of ventilation
Difficulty of maneuver
Rain
Muddy site
Fishbone Diagram
Poor inspection
method .
Inadequate material
inspection
Too old
Drugs
Root Causes

Root Cause Analysis Tree
Direct Cause
Actual description of the result of an accident. (e.g.
employee received acid burn to arm)
Obvious Cause or Secondary contributing factors
Readily observable causes of an accident. (e.g.
employee was not wearing proper PPE)
Root Cause or Primary Cause
Primary cause(s) of an accident, that when corrected
will prevent reoccurrence. ( e.g. employees not trained
properly regarding proper PPE to be worn for handling
hazardous chemicals.)
Root Causes

Incident or Injury
Obvious Causes
Root Causes Root Causes Root Causes Root Causes
Root Causes

Eye Injury
Use of PPE
Goggles not right
size
Faulty
Equipment
Insufficient Space
Review wet-station
layout Lack of knowledge Size not available
PM on equipment
Equipment
Review
Lack of
Training
PPE not
Available
Check
Equipment
Root Causes

Guide for Identifying Causal
Factors and Corrective Actions
 Identifies all of the causal factors of an
accident.
 Assigns corrective actions to them.
 If the causal factors are not eliminated, there
may be the possibility of another accident.
Root Causes

Guide for Identifying Causal Factors
and Corrective Actions
The Guide contains 5
parts:
 Equipment
 Environment
 People
 Management
 Ergonomics
Root Causes

 All major actions are considered.
 The analysis does not stop with familiar
and favorite corrective actions.
 Each corrective action chosen for
implementation is carefully thought out.
The Guide Ensures 3 Basic Steps
Root Causes

Formulating solid corrective action plans
and executing them is essential for:
 Getting results from an investigation,
and
 Preventing reoccurrence.
Corrective Action Plans
Root Causes

 A detailed and comprehensive description of
the Corrective Action
 An experienced owner who will take
responsibility for completing the Corrective
Action
 An estimated time of completion
3 Elements of Corrective Actions
Root Causes

LEGAL IMPLICATIONS

Legal Implications
Accident
Investigation Report
may be used in a
court of law.
Legal Implications

Legal Implications
 Any document could be used
as evidence.
 As an investigator, you could
be called as a witness.
 All documentation is legally
binding.
Legal Implications

What are the Legal Considerations?
Since the Accident Investigation Report
can be used in legal proceedings:
 Be thorough in describing what
happened.
 State facts and data only and don’t
state your opinions.
 Do not use language that assigns or
implies speculation or legal fault (like
the terms negligent or incompetent).
Legal Implications

Legal Considerations
 Good investigations are essential to prevent
future accidents and protect the corporation from
litigation.
 List ALL causes (especially Root Causes)
uncovered in your investigation.
 Make recommendations for corrective actions.
 Failure to correct a known hazard places the
employer at risk for being held negligent if
someone were to sustain an injury in the same
manner.
Legal Implications

SUMMARY:
DID WE MEET OUR
OBJECTIVES?

HSE - Accident Investigation.PPT

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