Slide 1: Accident
Investigation Why Investigate Accidents? : Why Investigate Accidents? Find the cause
Prevent similar accidents
Protect company interests Investigation is 4 Step Process : Investigation is 4 Step Process Control the Scene
Write Report Control the Scene : Control the Scene Provide medical care for injured
On Scene Evaluation
Transport for Medical Care
Control existing hazards
Prevent further injuries
Get more help if needed
Preserve evidence Gather Data : Gather Data Photos of accident scene
Drawings & sketches & measurements
Date, time, location
Activities at time of accident
List of witnesses Information Interviews : Information Interviews Gather just the facts… make no judgments or statements
Conduct interviews one on one
Be friendly but professional
Conduct interviews near the scene in private
Interview all supervisors Ask all witness : Ask all witness Name, address, phone number
What did you see
What did you hear
Where were you standing/sitting
What do you think caused the accident
Was there anything different today Ask Supervisors : Ask Supervisors What is normal procedure for activities involved in the accident
What type of training persons involved in accident have had.
What, if anything was different today
What they think caused the accident
What could have prevented the accident Analyze Data : Analyze Data Gather all photos, drawings, interview material and other information collected at the scene.
Determine a clear picture of what happened
Formally document sequence of events Data Analysis List : Data Analysis List Accident Title
Date, Time, Location
Work & Environmental Conditions at time of accident
Immediate actions taken at scene Basic Causes : Basic Causes Unsafe Acts – what activities contributed to the accident
Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident Contribution of Safety Controls such as : Contribution of Safety Controls such as Engineering Controls - machine guards, safety controls, isolation of hazardous areas, monitoring devices, etc.
Administrative Controls - procedures, assessments, inspection, records to monitor and ensure safe practices and environments are maintained.
Training Controls - initial new hire safety orientation, job specific safety training and periodic refresher training. What controls failed? : What controls failed? List the specific engineering, administrative and training controls that failed and how these failures contributed to the accident. What controls worked? : What controls worked? List any controls that prevented a more serious accident or minimized collateral damage or injuries. Determine : Determine What was not normal before the accident
Where the abnormality occurred
When it was first noted
How it occurred. Unsafe Acts : Unsafe Acts List all unsafe acts involved in the accident
Examples of unsafe acts
Unauthorized operation of equipment
Running - Horse Play
Not following procedures
By-passing safety devices
Not using protective equipment
Under influence of drugs or alcohol
Taking short-cuts Unsafe conditions : Unsafe conditions List all unsafe conditions involved in the accident
Examples of unsafe conditions
Improper or damaged PPE
Inadequate machine guarding Change Analysis : Change Analysis 1. Define the problem (What happened?).
2. Establish the norm (What should have happened?).
3. Identify, locate, and describe the change (What, where, when, to what extent).
4. Specify what was and what was not affected.
5. Identify the distinctive features of the change.
6. List the possible causes.
7. Select the most likely causes. Prevention : Prevention What needs to change or be improved to prevent similar accidents in the future?
Training Controls Final Report : Final Report Background Information – where, when, who & what
List of those involved & other witnesses
Account of the Accident - sequence of events, extent of damage, accident type, source Report Causes : Report Causes Analysis of the Accident – HOW & WHY
a. Direct causes (energy sources; hazardous materials)
b. Indirect causes (unsafe acts and conditions)
c. Basic causes (management policies; personal or environmental factors) Recommendations : Recommendations Action to remedy
Recommendations - as a result of the finding is there a need to make changes to:
Work Stations Design
Policies or procedures Send & File Report : Send & File Report After developing a formal report, forward it for review & action.
File a copy of the report and all raw data, photos, interview notes, etc. in a single file