Accident Investigation

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  • ALL accidents & near misses MUST be investigated Nearly ALL accidents can be prevented - we should only blame God for about 2% of them, the rest is up to us. Accident Investigation is NOT a method of trying to establish blame - simply a method of identifying the causes in order to prevent a recurrence Accidents, injuries and illnesses cost Australia between 10 and 20 BILLION dollars per year. That is only the reported or “insured” costs. A ratio of 4:1 is regarded as the norm by industry experts - could this mean that there is actually between 40 and 80 billion dollars being spent every year ?
  • Incident is an undesired event that could (or does) downgrade the efficiency of the business operation
  • Numerous organisations may have a variety of names for various incidents and to that end we must establish known protocols so that we all have an idea of what we are talking about. Refer to legislative requirements for appropriate terminology if there is any question, and wherever a report is the be submitted for legal reasons the correct terminology should be used or alternative descriptions should be provided.
  • Source: “Planning Occupational Safety & Health -(3rd Edition) {CCH}
  • Accidents will have many causes that can be identified by careful and thorough investigation. By identifying the causes we can establish safety solutions (prevention) Some causes may not always be seen by the investigator, therefore a team approach or additional expertise (workers?) may be beneficial
  • Not wise to talk about long lists of unsafe act or unsafe conditions Terms of standard practices and standard conditions
  • This is the area where most causes can be located and where effective Quality Assurance programs are in place, may of these causes have the potential to be eradicated Organisation policy and procedures should identify and outline specific safety requirements and ensure compliance
  • In any incident or accident involving death or a serious fire situation, it will be inevitable that a coronial inquest will be conducted. It is therefore crucial that all the facts and supporting documentation, samples and evidence are collated, adequate and complete, ready for presentation
  • In-house accident investigation for minor, or less serious accidents, and near misses should be conducted in an effort to eliminate, or at least reduce any possibility of a recurrence In the case of notifiable injury or accident, the Division of Workplace Health & Safety may wish to get involved and conduct an investigation themselves. An Inspector conducting an investigation may request (or demand) the assistace of WH&S Officers, representatives or any other worker An investigation almost certainly determine inadequacies with the management system, and it is therefore crucial that management support is gained to identify such inadequacies. Again this must NOT be seen as a blame apportioning exercise where workers may blame management, it should be seen as a consultative approach to improve these sytems
  • The investigator does not need to be a rocket scientists, simply someone with an understanding of the workplace and an inquisitive, objective nature. A degree of tact is required, especially when considering injuries to workmates. Show some sympathy and understanding
  • The first priority will be to ensure the victim is being treated and not exposed to further risk, and that professional help is being provided. Prevention of any further accident or incident must also be a priority and here we may consider such things ass: electric shock fire or explosion hazardous substance leak or spill machinery shut-down make safe, shore up Seal off the area to ensure scene interference is minimised and any evidence is preserved
  • Need to seal off the area ? Is it safe now ?
  • It must be a seeking of the truth through fact, NOT assumptions or theories There will be a variation in perceptions of different people, seeing the accident in different ways and then adding their interpretations to the incident. It is vital that the investigator can sift through this information and view it objectively. This may sometimes be hard to do if the accident being investigated is that of a colleague. A number of factors may need to be factored into the equation such as: day - Monday morning! Friday afternoon! time - lunch, knock off, early morning (sun) illumination noise climate - hot, humid, cold, slippery Objectively seek the following: Who? Where? When? What? How? Why?
  • It is important to put the interviewee at ease to elicite full, comprehensive and unbiased responses to your questions Confirm that this is not a “witchhunt” or blame placing exercise, simply a need to establish cause and to prevent recurrence Where possible use interview or witness checklist to remind you of pertinent questions and methods Encourage the witness to speak openly and freely and if points need clarification, do not hesitate to ask questions, or request elaboration If you are using audio tape recorder - ask permission first Ask “open” questions - more “what” than “did you” questions which may result in “yes”, “no” answers If necessary ask the witness to repeat salient points Can the witness offer any suggestions as to the reason for the accident and could they offer any suggestions that may reduce any further possibility of a recurrence Encourage the witness to get back to you if they remember any further information Ensure that you get back to the witness with your findings and recommendations Thank the witness for their time and frankness
  • Target the reader - Who is the reader? Discuss the “Queens Street Accident” (Concrete slab kills 3 members of the public) multi volume report Target audience was: Public prosecutor Principal Contractor Site owner (Bank) Victims representatives Government Div WH&S Police It would be a distinct advantage if the investigator or person(s) producing the report have undergone formal training in report writing techniques Set out in an appropriate format to be easy to read and understand (ABC) Don’t get too technical, it may confuse the reader (KISS) Recommendations must have time frame priorities and there MUST be a method of reviewing any control measures - Did they actually work?
  • Checklists including: victim checklist witness checklist environment checklist equipment checklist There are numerous documents that may assist the investigator, which may include: Medical & accident records hazard reports SOPs Job safety analysis work sheets inspection reports maintenance records Certificates of Competency MSDSs Permits to work Training records Risk Assessment
  • In Queensland on average one person in 20 will be seriously injured on the job every year More people DIE of accidents on the job than Stroke, Heart Attack or Cancer
  • There is a possibility of social stressors taking part also, especially in small work groups where a cross section of levels form social groups, ie fishing trips family gatherings social outings (drinking, darts etc) There may also be the potential for other workers to identify the supervisor as ineffective or incompetent Stress takes many forms and all those factors previously mentioned will undoubtedly take an effect as psychological hazard
  • The above relates specifically to expenditure but there is also a profound effect in terms of time. This will include the time spent : investigating training supervising reporting talking about it! Conduct exercise relating to costs of worker injured changing light globes
  • Handout of “Iceberg Effect” Conduct accident investigation - “Trans Accident”
  • Setting achievable safety goals at all levels and ensure ownership of specific safety objectives Commitment must be sought and maintained by all levels within the workplace, but the start must be made by management to ensure continued support Management must ensure sufficient resources are funded and available and encouragement provided Safety performance must be measured by using various tools, such as: workplace audits & inspections risk assessments job safety analyses frequency rates (number of injuries*1,000,000 divided by man hrs worked) duration rates (working hrs lost divided by number of injuries) Training and retraining will ensure correctness and consistency as well as a confident level of knowledge, leading to act or react in an informed manner, by recognising hazards and controlling them before they become a problem There are a huge variety of books, codes of practice, Australian Standards and a host of other materials that may be called upon to assist, as well as pictorial assistance in the form of posters, brochures and booklets Safety Incentive Schemes is a large bone of contention in the industry but is worth discussing and evaluating on an individual basis
  • Remember that fatal accidents will necessitate the involvement of the police as well as the Division of Workplace Health & Safety Many organisations subscribe to EAPs (Employee Assistance Programs) where professional help can be provided by experts, especially after traumatic events at work, such as serious accidents and death.
  • Accident Investigation

    1. 1. Accident & Incident Prevention & Investigation by Robert Behm
    2. 2. Course Objectives & Outcomes <ul><li>Understand the need to investigate </li></ul><ul><li>Know what to investigate </li></ul><ul><li>Determine the causes of accidents </li></ul><ul><li>Identify the methods of investigation </li></ul><ul><li>Understand the need to be thorough and comprehensive </li></ul><ul><li>Identify prevention methods </li></ul><ul><li>Identify sources of assistance </li></ul>
    3. 3. What is an Accident ? <ul><li>Any undesired, unplanned event arising out of employment which results in physical injury or damage to property, or the possibility of such injury or damage. </li></ul><ul><li>“ Near hit” situations must also be addressed - events which did not result in injury or damage but had the potential to do so. </li></ul>
    4. 4. What’s in a name ? <ul><li>Accident </li></ul><ul><li>Injury </li></ul><ul><li>Dangerous Occurrence </li></ul><ul><li>Significant Incident </li></ul><ul><li>“ Near-miss” accident </li></ul>
    5. 5. 1 10 30 600 Serious or Disabling Includes disabling & Serious Injuries Minor Injuries Any reported injury less than serious Property Damage & Accidents All Types Accidents with no visible Injury or Damage (Critical Incidents) Accident Ratio Study
    6. 6. Accident Causes <ul><li>Unsafe Act </li></ul><ul><ul><li>an act by the injured person or another person (or both) which caused the accident; and/or </li></ul></ul><ul><li>Unsafe Condition </li></ul><ul><ul><li>some environmental or hazardous situation which caused the accident independent of the employee(s) </li></ul></ul>
    7. 7. Accident Causation Model <ul><li>1. Results of the accident - (harm or damage) </li></ul><ul><li>2. Incident - Contact (Accident) </li></ul><ul><li>3. Immediate causes (symptoms) </li></ul><ul><li>4. Basic causes (real problems) </li></ul>
    8. 8. 1 . Results of the Accident (Humane & Economic Aspects) <ul><li>Physical harm (Injury or illness) </li></ul><ul><ul><li>catastrophic (multiple deaths) </li></ul></ul><ul><ul><li>death </li></ul></ul><ul><ul><li>disabling, lost time, major </li></ul></ul><ul><ul><li>serious </li></ul></ul><ul><ul><li>minor </li></ul></ul><ul><ul><li>notifiable </li></ul></ul><ul><ul><li>compensatable </li></ul></ul><ul><li>Property damage </li></ul><ul><ul><li>catastrophic </li></ul></ul><ul><ul><li>major </li></ul></ul><ul><ul><li>serious </li></ul></ul><ul><ul><li>minor </li></ul></ul>
    9. 9. 2. Incident - Contact (Accident) <ul><ul><li>struck against </li></ul></ul><ul><ul><li>struck by </li></ul></ul><ul><ul><li>fall to below </li></ul></ul><ul><ul><li>fall on same level </li></ul></ul><ul><ul><li>caught on </li></ul></ul><ul><ul><li>caught in </li></ul></ul><ul><ul><li>caught between </li></ul></ul><ul><ul><li>over exertion </li></ul></ul><ul><ul><li>chemical contact </li></ul></ul><ul><li>Contact with </li></ul><ul><ul><li>electricity </li></ul></ul><ul><ul><li>plant & equipment </li></ul></ul><ul><ul><li>noise or vibration </li></ul></ul><ul><ul><li>hazardous substances </li></ul></ul><ul><ul><li>radiation </li></ul></ul><ul><ul><li>heat & cold </li></ul></ul><ul><ul><li>animals or insects </li></ul></ul><ul><ul><li>microbiological agents </li></ul></ul>
    10. 10. 3. Immediate Causes (Symptoms) <ul><li>Standard Practices </li></ul><ul><ul><li>operating with authority </li></ul></ul><ul><ul><li>use serviceable equipment </li></ul></ul><ul><ul><li>use equipment properly </li></ul></ul><ul><ul><li>use of PPE where required </li></ul></ul><ul><ul><li>correct lifting </li></ul></ul><ul><ul><li>no drinking & drugs </li></ul></ul><ul><ul><li>no horseplay </li></ul></ul><ul><ul><li>secure equipment or warnings </li></ul></ul><ul><li>Standard Conditions </li></ul><ul><ul><li>effective guards & devices </li></ul></ul><ul><ul><li>serviceable tools & equipment </li></ul></ul><ul><ul><li>adequate warning systems </li></ul></ul><ul><ul><li>good housekeeping </li></ul></ul><ul><ul><li>non polluted environment </li></ul></ul><ul><ul><ul><li>noise </li></ul></ul></ul><ul><ul><ul><li>hazardous substances </li></ul></ul></ul><ul><ul><li>good illumination & ventilation </li></ul></ul><ul><ul><li>good working, storage & travelling space </li></ul></ul>
    11. 11. 4.Basic Causes (The Real Problem) <ul><li>Personal Factors </li></ul><ul><ul><li>lack of knowledge or skill </li></ul></ul><ul><ul><li>improper motivation </li></ul></ul><ul><ul><li>physical or mental conditions </li></ul></ul><ul><ul><li>literacy or ability (NESB) </li></ul></ul><ul><li>Job Factors </li></ul><ul><ul><li>physical environment </li></ul></ul><ul><ul><li>sub-standard equipment </li></ul></ul><ul><ul><li>abnormal usage </li></ul></ul><ul><ul><li>wear & tear </li></ul></ul><ul><ul><li>inadequate standards </li></ul></ul><ul><ul><li>design & maintenance </li></ul></ul><ul><li>Supervisory Performance </li></ul><ul><ul><li>inadequate instructions </li></ul></ul><ul><ul><li>failure of SOPs </li></ul></ul><ul><ul><li>rules not enforced </li></ul></ul><ul><ul><li>hazards not corrected </li></ul></ul><ul><ul><li>devices not provided </li></ul></ul><ul><li>Management Policy & Decisions </li></ul><ul><ul><li>set measurable standards </li></ul></ul><ul><ul><li>measure work in progress </li></ul></ul><ul><ul><li>evaluate work-v-standards </li></ul></ul><ul><ul><li>correct performance if necessary </li></ul></ul>
    12. 12. Why Investigate ? <ul><li>Legal Requirement </li></ul><ul><li>Establish Causes </li></ul><ul><li>Prevent Recurrences </li></ul><ul><li>Accurate record (courts & enquiries) </li></ul><ul><li>Statistical data base </li></ul>
    13. 13. What is Accident Investigation ? <ul><li>A systematic approach to accident investigation, the identification of causal factors and implementation of corrective actions is essential to a good H&S program. Good procedures: </li></ul><ul><ul><li>provide information needed to determine injury rates, identify trends or problem areas, permit comparisons and satisfy Workers Compensation requirements; </li></ul></ul><ul><ul><li>identify, without placing blame , the basic causal factors that contributed directly or indirectly to each accident; </li></ul></ul><ul><ul><li>identify deficiencies in management systems; </li></ul></ul><ul><ul><li>suggest corrective action alternatives for a given accident; </li></ul></ul><ul><ul><li>suggest corrective action alternative. </li></ul></ul><ul><ul><li>What can we do to prevent this from recurring. </li></ul></ul>
    14. 14. What, When & How to Investigate <ul><li>What to Investigate ? </li></ul><ul><ul><li>all accidents & near misses </li></ul></ul><ul><ul><li>as soon as possible </li></ul></ul><ul><ul><li>scene interference </li></ul></ul><ul><ul><li>survey of scene </li></ul></ul><ul><ul><li>chronology of data </li></ul></ul><ul><ul><li>measurements, maps & sketches </li></ul></ul><ul><ul><li>eyewitnesses </li></ul></ul><ul><li>Who should Investigate? </li></ul><ul><ul><li>Supervisor ? </li></ul></ul><ul><ul><li>H&S Officer? </li></ul></ul><ul><ul><li>Team? </li></ul></ul><ul><li>Training & Skills </li></ul><ul><ul><li>investigative & recording skills </li></ul></ul><ul><ul><li>technical knowledge </li></ul></ul><ul><ul><li>interviewing skills </li></ul></ul><ul><ul><li>report writing skills </li></ul></ul>
    15. 15. The Investigator’s Qualifications <ul><li>Technical Knowledge </li></ul><ul><li>Objectivity </li></ul><ul><li>Analytical approach to problems </li></ul><ul><li>Familiarity with the job, process or operation </li></ul><ul><li>Tact in communicating </li></ul><ul><li>Intellectual honesty </li></ul><ul><li>Inquisitiveness & curiosity </li></ul>
    16. 16. Let Us Begin ! <ul><li>Take all necessary steps to provide emergency rescue and medical help for the injured; and </li></ul><ul><li>take those actions that will prevent, or minimize the risk of further accidents or physical harm to the victim or others </li></ul>
    17. 17. Determine the Facts <ul><li>Visit accident scene </li></ul><ul><li>Take samples </li></ul><ul><li>Visual records </li></ul><ul><li>Preserve accident items </li></ul><ul><li>Identify people involved </li></ul><ul><li>Interview witnesses </li></ul><ul><li>Review information </li></ul>
    18. 18. Finding Facts (logic method) <ul><li>What was the exact injury or damage ? </li></ul><ul><li>What was the cause ? </li></ul><ul><li>What event immediately preceded the damaging event ? </li></ul><ul><li>What happened before that ? </li></ul><ul><li>What happened even before that ? </li></ul><ul><li>What happened in between ? </li></ul><ul><li>What else was going on at the time of the accident ? </li></ul><ul><li>Was anyone else involved ? </li></ul><ul><li>Interview witnesses </li></ul>
    19. 19. Interviewing Techniques <ul><li>Put at ease </li></ul><ul><li>Assure “no blame” </li></ul><ul><li>Ask witness to relate their account of the accident </li></ul><ul><li>Listen carefully </li></ul><ul><li>Ask questions - reinforce </li></ul><ul><li>Repeat if necessary </li></ul><ul><li>Ask witness for suggestions for future avoidance </li></ul><ul><li>Encourage further contact </li></ul><ul><li>Be polite and thank the witness </li></ul>
    20. 20. A Good Report <ul><li>Accuracy & completeness of information </li></ul><ul><li>Clarity & completeness of of the description of the sequence of events leading up to the accident </li></ul><ul><li>Correct identification of all causal factors </li></ul><ul><li>Clarity & completeness of all causal factors </li></ul><ul><li>Recommendations made for corrective actions to reduce or eliminate the probability of recurrence of a similar accident </li></ul><ul><li>Recommendations for corrective actions to improve management system </li></ul><ul><li>Timelines - specific time periods, monitoring and responsibilities </li></ul><ul><li>Proper review and sign off </li></ul>“ A GOOD REPORT” BY CLEVER DICK
    21. 21. Supporting Documentation <ul><li>Accident investigation Form </li></ul><ul><li>Witness Statements & Records of Interview </li></ul><ul><li>Checklists: </li></ul><ul><ul><li>Victim(s) </li></ul></ul><ul><ul><li>Witnesses </li></ul></ul><ul><ul><li>Environment & Locations </li></ul></ul><ul><ul><li>Equipment & Parts </li></ul></ul><ul><ul><li>Documentation </li></ul></ul><ul><li>Accident/Incident Record </li></ul>
    22. 22. The effects of Accidents <ul><li>1. On the Victim </li></ul><ul><li>2. On the Supervisor </li></ul><ul><li>3. On the Institution </li></ul><ul><li>4. On the Nation </li></ul>
    23. 23. 1. The Victim <ul><li>Death </li></ul><ul><li>Pain & suffering </li></ul><ul><li>Permanent disability </li></ul><ul><li>Effects on family & dependants </li></ul><ul><li>Loss of earnings </li></ul><ul><li>Extra expenditure </li></ul><ul><li>Inability to resume occupation </li></ul><ul><li>Psychological effects </li></ul><ul><li>Feeling of uselessness </li></ul><ul><li>Fear of further injury </li></ul><ul><li>Social effects </li></ul><ul><li>Loss of sports or hobby </li></ul>
    24. 24. 2. The Supervisor <ul><li>loss of trained worker </li></ul><ul><li>extra work (overtime) </li></ul><ul><li>investigations & reports </li></ul><ul><li>training new employee </li></ul><ul><li>worry (could I have prevented it ?) </li></ul><ul><li>Stress </li></ul>
    25. 25. 3. The Institution <ul><li>loss of trained worker </li></ul><ul><li>damage to machinery </li></ul><ul><li>damage to equipment </li></ul><ul><li>wasted materials </li></ul><ul><li>Worker’s comp costs </li></ul><ul><li>prosecutions </li></ul><ul><li>fines </li></ul><ul><li>civil actions </li></ul><ul><li>legal costs </li></ul><ul><li>loss of prestige - public </li></ul>
    26. 26. 4. The Nation <ul><li>loss of section of workforce </li></ul><ul><li>loss of production </li></ul><ul><li>increased cost of production </li></ul><ul><li>effects on imports </li></ul><ul><li>effects on exports </li></ul><ul><li>effects on balance of trade </li></ul><ul><li>the taxpayers pay ! </li></ul>
    27. 27. Can Accidents be Prevented ? <ul><li>Effective Management & Supervision </li></ul><ul><li>Commitment to Accident Prevention </li></ul><ul><li>Effective Policy & Procedures </li></ul><ul><li>Effective Reporting & Recording </li></ul><ul><li>“ Tailgate” Meetings </li></ul><ul><li>Risk Assessments </li></ul><ul><li>Specific Training </li></ul><ul><li>Literature & Culture </li></ul><ul><li>Incentive Schemes ? </li></ul>
    28. 28. Warning Signs <ul><li>Increases in breaches of safety procedures </li></ul><ul><li>Increase in reportable incidents </li></ul><ul><li>Technical concerns </li></ul><ul><li>Friction or disputes </li></ul><ul><li>Worn or suspect equipment </li></ul><ul><li>Introduction of new procedures or equipment </li></ul><ul><li>New employees </li></ul><ul><li>Age of employees </li></ul><ul><li>Long periods of work </li></ul><ul><li>Environmental issues </li></ul>
    29. 29. Resources <ul><li>Safety Officers </li></ul><ul><li>Departmental Health & Safety </li></ul><ul><li>State Comp. Insurance Fund </li></ul><ul><li>St. Joseph’s Occupational Health </li></ul><ul><li>Rehabilitation Experts </li></ul><ul><li>Employee Assistance Programs </li></ul>

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