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
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Editor's Notes
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.
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