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OH NO! Now What Do I Do?: 

OH NO! Now What Do I Do? Accident Investigations Pamela A. Boatright, CIH University of Oklahoma Health Sciences Center

What is an Accident?: 

What is an Accident? An accident is any unplanned event that results in personal injury or in property damage.

Why Investigate? : 

Why Investigate? Accident investigation concentrates on gathering all information about the factors leading to an accident. The goal is preventing future accidents and injuries.

Why Investigate? : 

Why Investigate? Determine direct causes Uncover contributing causes Prevent similar accidents Document facts Provide information on costs Promote safety

Determine Direct Causes : 

Determine Direct Causes Hazard control system failure? Rules and regulations broken? Defective machinery? Poor layout of workspace?

Uncover Contributing Causes: 

Uncover Contributing Causes Other factors may be: Poor housekeeping Failure to follow maintenance schedules Inadequate supervision Faulty equipment

Prevent Similar Accidents: 

Prevent Similar Accidents Identification may help prevent similar accidents in the future by identifying needed actions and improvements.

Document Facts: 

Document Facts Compensation and litigation issues A permanent record of facts Accident reconstruction may be needed Facts must be recorded properly, accurately and thoroughly

Provide Information on Costs: 

Provide Information on Costs Direct Costs Indirect Costs

Promote Safety: 

Promote Safety Psychological and material benefits Demonstrates the organization’s interest Indicates management’s sense of accountability and commitment to safety Fact-finding, not Fault-finding process

Be empathetic : 

Be empathetic Treat employees with respect People do not like pain Do not make assumptions Be sensitive to the fact that the injured party may be embarrassed and defensive Seek to fix the problem, not the blame

Cases to be Investigated : 

Cases to be Investigated All on-the-job injuries, exposures or illnesses should be reported Near-misses may hold important clues about potential accidents and should be reported also

Accident Causes and Their Control: 

Accident Causes and Their Control Every accident can be attributed, directly or indirectly to: Human factors (the worker or another person) Situational factors (facilities, tools, equipment, or materials) Environmental factors (noise, vibration, temperature extremes, illumination)

Human Factors: 

Human Factors Any person who by action or failure to act causes an accident deviation from standard operating procedures deviation from safety rules and training WHY??

Why? : 

Why? No safe job procedures exist The employee did not know the standard job procedure Employee knew, but did not follow the procedures Employee followed procedures

Why? : 

Why? Procedure encourages risk-taking Employee changed the job procedure or by-passed safety procedures Employee did not follow procedures because of the supervisor Individual characteristics

Situational Factors: 

Situational Factors Hazardous Materials Unsafe operations Tools Equipment Facilities

Environmental Factors: 

Environmental Factors Physical - noise, vibration, radiation, lighting, temperature Chemical - toxic gas or vapors, fumes, mists, smoke Biological - bacteria, fungi, parasites, insects, plants Ergonomic - awkward or repetitive actions that place stress on the body

Sources of Situational or Environmental Hazards: 

Sources of Situational or Environmental Hazards Purchasing agents Maintenance personnel Employees

Examining Accident Causation: 

Examining Accident Causation After-the-fact Before-the-fact Critical Incident Technique Safety Sampling

After-the-fact: 

After-the-fact Crucial Questions: Who? How? What? Why? When? (and following sequence) Where?

Eight Data Elements: 

Eight Data Elements Employer data Employee data Narrative Description Equipment Task description Time Factors Nature of Injury Preventive Measures

Fact-Finding: 

Fact-Finding Interview witnesses as soon as possible, Inspect the accident site before any changes occur. Take photographs and make sketches. Record pertinent data in maps. Get copies of all reports. Keep accurate notes in a bound notebook.

Fact-Finding: 

Fact-Finding Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities may be useful. Record pre-accident conditions, the accident sequence, and post-accident conditions.

Fact-Finding: 

Fact-Finding Document the location of victims, witnesses, machineryk, energy sources, and hazardous materials. Call in experts if needed.

Interviews: 

Interviews Get preliminary statements as soon as possible from witnesses. Locate the position of witnesses on a map or chart. Explain the purpose (prevention) and try to put the witness at ease. Let the witness speak freely and take notes without distracting him/her.

Interviews: 

Interviews Use a tape recorder only with the permission of the witness. Use sketches and diagrams to help the witness. Make note of direct observations versus hearsay. Try to use the exact words used by the witness.

Interviews: 

Interviews Word questions carefully and repeat or reword if the witness does not undestand the question. Identify the qualifications of each witness (name, address, occupation, years of experience, etc.). Supply each witness with a copy of their statements (signed statements desirable).

Before-the-fact: 

Before-the-fact Systematic approach to identifying and evaluating an accident before it occurs Critical Incident Technique Safety Sampling

Critical Incident Technique: 

Critical Incident Technique Ask a sampling of workers to describe job hazards Management classifies “incidents” into hazard categories and identifies problem areas A team can analyze the management systems in place that should have prevented the unsafe acts or conditions

Safety Sampling : 

Safety Sampling Uses expertise within the organization Make rounds to observe unsafe practices Make observations during different times of the day and throughout the jobsite

Resources and References: 

Resources and References http://www.osha.gov/ http://www.cdc.gov/niosh/homepage.html http://www.cdc.gov/ http://atsdr1.atsdr.cdc.gov:8080/ http://www.epa.gov/enviro/index_java.html http://ace.ace.orst.edu/info/extoxnet/ http://www.nsc.org/

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