Investigating Accidents

How to Iind out what really happened.

ourse Obiectives
Recognize the need for an investigation
nvestigate the scene of the accident
nterview victims & witnesses
Distinguish fact from fiction
Determine root causes
Compile data and prepare reports
Make recommendations
hat is an Accident ?
Any undesired, unplanned event arising out
oI employment which results in physical
iniury or damage to property, or the
possibility oI such iniury or damage.
'Near miss situations must also be
addressed - events which did not result in
iniury or damage but had the potential to do
so.
What is an Accident?
Any unplanned event that interrupts the
completion of an activity and has the potential to
include injury. illness. or property damage
hat is an Accident?
Unplanned event results in mishap (personal
iniury or property damage).
Accidents are the result oI the Iailure oI
people, equipment, materials, or
environment to react as expected.
All accidents have consequences or
outcomes.
%HE AIDEN%
ASI %!ES OF AIDEN%S
%HE AIDEN%
INOR AIDEN%S:
Such as paper cuts to Iingers or dropping a
box oI materials.
%HE AIDEN%
ore serious accidents that cause iniury or
damage to equipment or property:
Such as a IorkliIt dropping a load or
someone Ialling oII a ladder
%HE AIDEN%
Accidents that occur over an extended time
Irame:
$uch as hearing loss or an illness resulting
from exposure to chemicals
%HE AIDEN%
NEAR-ISS
Also know as a 'Near Hit
An accident that does not quite result in
iniury or damage (but could have).
Remember, a near-miss is iust as serious as
an accident!
%HE AIDEN%
AIDEN%S HAVE %O %HINGS IN
OON
%HE AIDEN%
%hey all have outcomes Irom the accident
%HE AIDEN%
%hey all have contributory Iactors that cause
the accident
OU%OES OF AIDEN%S
NEGA%IVE AS!E%S
njury & possible death
Disease
Damage to equipment & property
Litigation costs. possible citations
Lost productivity
Morale
ost oI Accidents:
%he Iceberg EIIect
n average. the
indirect costs of
accidents exceed the
direct costs by a 4:1
ratio
ceberg Analogy
Accident Cost
edical !ayments
ompensation
Supervisor time to investigate
reaking in substitute
!oor eIIiciency due to
break-up oI crew
Damaged tools/equipment
Down-time
Overhead $ while work disrupted
Failure to meet deadline/Iill orders
Loss oI production
Loss oI good will
Overtime to make up production
Hiring costs
Lost time by Iellow workers
Direct Costs
ndirect or Hidden
Costs
onsequences oI Accidents
Direct onsequences
1. !ersonal iniury
2. !roperty loss
Indirect onsequences
1. Lost income
2. edical expenses
3. %ime to retrain
another person
4. Decreased employee
moral
OU%OES OF AIDEN%S
!OSI%IVE AS!E%S
Accident investigation
Prevent recurrence
Change to safety programs
Change to procedures
Change to equipment design
%he Aim oI the Investigation
%he key result should be to prevent a
recurrence oI the same accident.
Fact Iinding:
hat happened?
hat was the root cause?
hat should be done to prevent recurrence?
t is not to assign blame
%ypes oI Accidents
ALL T
same level
lower level
CAUGHT
in
on
between
CTACT TH
chemicals
electricity
heat/cold
radiation
BDLY
REACT RM
voluntary motion
involuntary motion
%ypes oI Accidents (continued)
$TRUCK
Against
stationary or moving
object
protruding object
sharp or jagged edge
By
moving or flying
object
falling object
RUBBED R
ABRADED BY
friction
pressure
vibration
%he Investigation
A step-by-step process (almost)
Investigation Strategy
Gather inIormation
Search Ior & establish Iacts
Isolate essential contributing Iactors
Find root causes
Determine corrective actions
Implement corrective actions
What are the basic steps in doing the accident investigation and report?
Step 1 - Secure the accident scene
Step 2 - Provide MedicaI Care to the Injured
Step 3 - IsoIate the accident scene
Step 4 - CoIIect facts about what happened
Step 5 - Determine the sequence of events
Step 6 - Determine the causes
Step 7 - Recommend improvements
Step 8 - Write the report
The process
Secure the Scene
Eliminate the hazards:
Control chemicals
De-energize
De-pressurize
Light it up
$hore it up
Ventilate
!rovide are to the Iniured
Ensure that medical care is provided to the
iniured people beIore proceeding with the
investigation.
Isolate the Scene
arricade the area oI the accident, and keep
everyone out!
!rotect the evidence until investigation is
complete
Ask 'hat Happened
Get a brieI overview oI
the situation Irom
witnesses and victims.
Not a detailed report yet,
iust enough to
understand the basics oI
what happened.
Interview Victims & itnesses
Interview as soon as
possible aIter the incident
Do not interrupt medical
care to interview
Interview each person
separately
Do not allow witnesses to
conIer prior to interview
%he Interview
!ut the person at ease.
People may be reluctant to
discuss the incident.
particularly if they think
someone will get in trouble
Reassure them that this is a
Iact-Iinding process only.
Remind them that these
facts will be used to prevent
a recurrence of the incident
%he Interview
%ake Notes!
Ask open-ended questions
hat did you see?
hat happened?
Do not make suggestions
f the person is stumbling over a word or
concept. do not help them out
%he Interview
Use closed-ended questions later to gain
more detail.
After the person has provided their
explanation. these type of questions can be
used to clarify
here were you standing?
hat time did it happen?
%he Interview
Don`t ask leading questions
Bad: hy was the forklift operator driving
recklessly?
Good: How was the forklift operator
driving?
II the witness begins to oIIer reasons,
excuses, or explanations, politely decline
that knowledge and remind them to stick
with the Iacts
%he Interview
Summarize what you have been told.
Correct misunderstandings of the events
between you and the witness
Ask the witness/victim Ior
recommendations to prevent recurrence
These people will often have the best
solutions to the problem
Gather Evidence
Examine the accident scene. Look Ior things
that will help you understand what happened:
Dents. cracks. scrapes. splits. etc. in equipment
Tire tracks. footprints. etc.
$pills or leaks
$cattered or broken parts
Etc.
Gather Evidence
Diagram the scene
Use blank paper or graph
paper. Mark the location of
all pertinent items;
equipment. parts. spills.
persons. etc.
ote distances and sizes.
pressures and temperatures
ote direction (mark north
on the map)
Gather Evidence
%ake photographs
Photograph any items or scenes which may provide
an understanding of what happened to anyone who
was not there.
Photograph any items which will not remain. or
which will be cleaned up (spills. tire tracks.
footprints. etc.)
35mm cameras. Polaroids. and video cameras are all
acceptable.
Digital cameras are not recommended - digital images
can be easily altered
Review Records
heck training records
as appropriate training provided?
hen was training provided?
heck equipment maintenance records
s regular PM or service provided?
s there a recurring type of failure?
heck accident records
Have there been similar incidents or injuries
involving other employees?
INVES%IGA%ION %RA!S
Put your emotions aside!
Don`t let your feelings interfere -
stick to the facts! (The Eyes Glazed
ver)
Do not pre-judge.
ind out the what really happened.
Do not let your beliefs cloud the
facts.
ever assume anything.
Do not make any judgements.
ON%RIU%ING FA%ORS
EVRMETAL
DE$G (equipment/material)
$Y$TEM$ & PRCEDURE$
(management)
HUMA BEHAVR (people)
ON%RIU%ING FA%ORS
ENVIRONEN%AL
oise
Vapors. fumes. dust
Light
Heat
ON%RIU%ING FA%ORS
DESIGN
orkplace layout
Design of tools & equipment
Maintenance
ON%RIU%ING FA%ORS
SS%ES &
!ROEDURES
Lack of systems &
procedures
nappropriate systems
& procedures
Training in procedures
Housekeeping
ON%RIU%ING FA%ORS
HUMA BEHAVR
Common to all accidents
ot limited to the person involved in the
accident
DE%ERINE AUSES
Employee actions
$afe behavior. at-risk behavior
Environmental conditions
Lighting. heat/cold. moisture/humidity. dust. vapors. etc.
Equipment condition
Defective/operational. guards. leaks. broken parts. etc.
Procedures
Existing (or not). followed (or not). appropriate (or not)
Training
as employee trained - when. by whom. documentation
CausaI Factors
(1) Task
(2) MateriaI
(3) Environment
(4) Human Factor ( PersonaI)
(5) Management/Process FaiIure
MATERAL
EVRMET
MAAGEMET
TA$K
PER$AL
(1) Task
Ergonomics
Safety work procedures
Condition changes
Process
MateriaIs
Workers
Appropriate tooIs/materiaIs
Safety devices (incIuding Iockout)
(2) MateriaI
Equipment faiIure
Machinery design/guarding
Hazardous substances
Substandard materiaI
(3) Environment
Weather conditions
Housekeeping
Temperature
Lighting
Air contaminants
PersonaI Protective Equipment
(4) Human Factor (PersonaI)
LeveI of experience
LeveI of Training
PhysicaI capabiIity
HeaIth
Fatigue
Stress
(5) Management/Process FaiIure
VisibIe Active senior management support for
safety
Safety poIicies
Enforcement of safety poIicies
Adequate supervision
KnowIedge of hazards
Hazard corrective action
Preventive maintenance
ReguIar audits
Root auses
Root causes are the management system
weaknesses that allowed the casual Iactor to
occur:
1. Equipment design process
2. !rocedures
3. Supervision
4. Standards and !olicies
5. %raining
6. ommunication !ractices
7. aintenance !ractices
FIND ROO% AUSES
hen you have determined
the contributing factors. dig
deeper!
f employee error. what
caused that behavior?
f defective machine. why
wasn`t it fixed?
f poor lighting. why not
corrected?
f no training. why not?
%he %hree asic auses
!oor anagement SaIety !olicy & Decisions
!ersonal Factors
Environmental Factors
UnsaIe Act
UnsaIe
ondition
Unplanned release oI energy
and/or
Hazardous material
Basic Causes
ndirect Causes
ACCDET ACCDET
Personal njury
Property Damage
Examples oI Accident auses
Direct auses Indirect auses asic auses
Struck
by/against
Failure to secure No oversight
Falls Guarding !oor
maintenance.
aught
in/between
Improper use %raining
Exertion UnsaIe position !olicies
ontact with.. Environmental Stress
Impact (vehicle) DeIect Engineering
!RE!ARE A RE!OR%
Accident Reports should contain the
Iollowing:
Description of incident and injuries
$equence of events
Pertinent facts discovered during
investigation
Conclusions of the investigator(s)
Recommendations for correcting
problems
!RE!ARE A RE!OR%, ON%.
e obiective!
$tate facts.
Assign cause(s). not blame.
f referring to an individuals actions. don`t
use names in the recommendation.
Good: All employees should...
Bad: Ahmed should....
AKE REOENDA%IONS
DE%ERINE ORRE%IVE A%IONS
INVES%IGA%ION %EA
TERPRET$ & DRA$ CCLU$
D$TCT BETEE TERMEDATE
& UDERLYG CAU$E$
AKE REOENDA%IONS
DE%ERINE ORRE%IVE A%IONS
INVES%IGA%ION %EA
Recommendations based on key contributory
factors and underlying/root causes
AKE REOENDA%IONS
I!LEEN% ORRE%IVE A%IONS
VE$TGAT TEAM
Recommendation(s) must be communicated
clearly and objectively.
$trict time table established
ollow up conducted
O!AN AIDEN% FORS
ust be Iilled out completely by the
employee and employee`s immediate
supervisor (this includes Ioremen).
ust be turned in to SaIety within 24
hours oI incident.
ENEFI%S OF AIDEN%
INVES%IGA%ION
!REVEN%ING REURRENE
IDEN%IFING OU%-ODED
!ROEDURES
I!ROVEEN%S %O ORK
ENVIRONEN%
ENEFI%S OF AIDEN%
INVES%IGA%ION
INREASED !RODU%IVI%
I!ROVEEN% OF O!ERA%IONAL &
SAFE% !ROEDURES
RAISES SAFE% AARENESS LEVEL
ENEFI%S OF AIDEN%
INVES%IGA%ION
HEN AN ORGANIZA%ION REA%S
SIF%L AND !OSI%IVEL %O
AIDEN%S AND INJURIES, I%S
A%IONS REAFFIR I%S
OI%EN% %O %HE SAFE% AND
ELL-EING OF I%S E!LOEES
%HANK OU!
Remember, always dig deep Ior the answers.
Don`t suIIer Irom %EGO!
Example OI %itanic
Direct auses
April 1912
Hitting the ce-Berg
2000 (1500 passengers + 500 crews)
Indirect auses (Root auses)
Inadequate number oI liIeboats and delayed
regulation
No transverse overheads on bulkheads with
watertight doors
No shakedown (practice) cruise to train crew
No training Ior oIIicers on handling oI large
single rudder ships
Only one radio channel.
Not Enough LiIeboats
Number oI liIeboats per ton (weight oI chip)
no number oI liIeboats (seats) per person on
board.
ritish arine Regulations
%itanic is unsinkable??????
ad Design oI Doors
%he bulkheads, which are compartments below the water
line that are divided by partitions to prevent leakage or
spread oI Iire, could be sealed oII Irom one another by
closing watertight doors.
%hese bulkheads, that were assumed to be watertight
themselves did not have transverse overheads (sealed tops
or coverings).
hen the %itanic struck the iceberg and water Iilled the
Iirst damaged bulkhead, water began Ilowing Irom the top
oI that bulk head into the next.
ater Ilowed Irom one bulkhead into the next, causing
the titanic to sink.
No Shakedown or !ractice ruise
Although the ship`s oIIicers and sailors
were some oI the most experienced mariner
in the world, they had not worked together
as a crew, nor were they Iamiliar with the
ship.
One problem was that the man responsible
Ior looking did not know where to Iind the
binoculars.
No Special %raining
No special training was
provided Ior the ship`s oIIicers
on the handling emergencies
characteristics oI a ship the
size oI the %itanic.
%he oIIicer on the bridge
turned away Irom the iceberg
and put the ship`s engines in
reverse (stop)
He should have increased the
ship speed to miss the iceberg
or at least minimizing the area
oI contact.
Only One Radio hannel
In 1912, radio was iust coming
into use, and the radio operator,
r. !hillips, was busy sending
personal messages Irom the Iirst
class passengers who were
bragging about being on the
%itanic.
At the same time, ships in the
area were sending in warnings to
the %itanic about ice Iields ahead
oI them.
r. !hillips actually told ships to
stop transmitting iceberg
warnings because he had
importance messages to send
Irom his Iirst class passengers.
Accident Scenario #3 Accident Scenario #3
n Tuesday morning $MU employee Peruna reported to work to start his day. Peruna
has worked as a carpenter on campus for 31 years. (Peruna always wears his safety
glasses and follows safety procedures) n Tuesday Morning about 9:30 am Peruna
mentioned to his supervisor Car Rag Phelps (better known as CRP) that his left eye was
sore. He said some wood dust may have gotten in it while cutting boards to build the
stables for the $MU polo horses. CRP told him to go check it out in the mirror. hile
Peruna was looking in the mirror he could see a small amount of wood shavings in his
eye. Peruna went to the eye wash station and rinsed out his eye. After about 15 minutes
he reported back to CRP and finished the days work. The supervisor filed a quick
accident report and did not give the situation much more thought.
Later that night Peruna woke up about 2:00am and went to look in the mirror. He had
trouble opening his left eye and when he did get it open it was completely red and looked
infected. His wife. ilma Caustic (C) immediately took him to the emergency room.
hile at the hospital the doctors used a special dye and found a large amount of wood
shavings that needed to be removed. After the doctors removed the shavings C took
Peruna home but he did have to wear a patch over his left eye for a week while it healed.
hat should happen from here?
hat do you think is the root cause of this incident?
Example
Example
Friday (Holiday)
Security
elding without permit
SaIety easures
Equipment
Illumination & Ventilation
One hall (!roduction/Storage)
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nvestigation nto Glacial Acetic
Acid $pillage
%he Accident
An operator had dispensed 10.5 kg (23 lbs) of Glacial Acetic Acid
into 18.9 liters (5 gallons) plastic bucket (approximately half full).
He placed a lid on the container and started carrying it from
Building A to Building B.
After carrying the container a short distance. approximately 9 m
(30 ft) he noticed that the lid was beginning to fall off. As he set
the container down to straighten the lid it bumped a pallet.
This caused the container to tip. splashing Glacial Acetic Aced in
his face and eyes.
He immediately went to the safety shower. approximately 12 m.
(40 ft.) away and began to wash his face and eyes.
The water from this safety shower was so cold it took his breath.
After approximately five minutes. he got help from other
operators.
$ince there was no eye wash in the immediate area. he was taken
to the bathroom and water was poured into his eyes from the sink.
ontinue
The employee was transported to the hospital
after approximately 20-25 minutes.
Although he had received acid burns to the face
and eyes he returned to work two months later
with no permanent damage.
auses (ontributing Factors)
1. Equipment/aterial
2. Environment
3. !eople/anagement
4. Attitude
Equipment
1. The bucket used to transport Glacial Acetic
Acid was not big enough.
2. The bucket had a lid. but it could not be
secured without going to a lot of trouble.
nce secured. it would have to be cut in
several spots to be removed. This meant the
container could no longer be used.
3. hen lifted the bucket loses its shape.
causing the lid to slide off.
Environment
Glacial Acetic Acid is stored in Building
A and must be carried to Building B
through two sets of doors.
There were a lot of congestion in this
area. Construction work was in progress
and the area was cluttered.
Glacial Acetic Acid is very corrosive.
!eople (anagement)
The batch procedure states that when handling Glacial
Acetic Acid gloves and goggles must be worn. The plant
rule calls for adequate eye and body protection. t
seems face shield in addition to goggles when handling
corrosive materials have never been specified.
The employee knew that goggles and chemical gloves
were required. He only worn gloves.
The employee was trained to do the job by another
employee. hen he was trained he was instructed to
wear chemical gloves. o other personal protective
equipment was recommended during training.
A basic safety rule was broken; however. it had been
broken several times before (and since) the injury. This
violation had been ignored. o correction was made.
ontinue
There was no eye bath in the area. t is not
known if this factor contributed to the severity of
the injury. This unsafe condition had been
recognized. Eye bath had been ordered and
received. but not installed.
t was reported that personal protective
equipment is difficult to keep. or example. full
acid gear has been placed in this area since the
accident and it has disappeared twice.
Attitude
%his was the most oIten discussed Iactor
during the investigation. For Example
1. The employee says he never thought it would
happen to him.
2. Many negative comments were made when the
foreman gave each employee on his shift a pair
of goggles and instructed them to keep them
nearby.
3. ew buckets (stainless steel with lids) have been
purchased. A check of the operators reveals
that they are used part of the time.
ontinue
Even though basic safety rules had been
violated for some time. no one had made
any correction.
Corrective Action
ontainers
!rovide an adequate 'closed container Ior
handling or transporting corrosive material.
Label containers.
%rain people to handle corrosives.
EnIorce rules that will prevent the use oI
inadequate containers.
Attitude
Determine what method will be used to
ensure the proper procedures are Iollowed.
Supervision must detect and instruct.
Employees must Iollow procedures.
!!E
SpeciIy what equipment is required (goggles Iace
shields iackets trousers gloves) when handling
corrosives.
SpeciIy how this equipment will be obtained.
olor code acid gear it was the opinion oI some
committee members the the acid gear is missing
because people use it as rain gear. olor code the
acid gear and do not allow its all-purpose use.
Involve operators in the selection process oI !!E.