Accident Investigation

Copyright ¥Progressive Business Publications

Accidents and Near Misses 
An accident is:

± Any unplanned event that results in personal injury or in property damage ± The result of the failure of people, equipment or the surrounding environment to react as expected ± The result of a process of causes that culminates in a final event that cause injury or illness 
A near miss is:

± An incident that could have resulted in an accident
Copyright ¥Progressive Business Publications

Consequences of Accidents  Direct Consequences ± Personal injury ± Property loss  Indirect Consequences ± Lost income ± Medical expenses ± Lowered morale ± Training replacements ± Lost productivity Copyright ¥Progressive Business Publications .

Purpose of Accident Investigation  Determine the sequence of events leading to the accident  Determine the how and why the accident occurred by identifying causes  Prevent similar accidents in the future by: ± Recommending corrective actions ± Eliminating clearly identified hazards NOTE: The point of accident investigation is NOT to place blame Copyright ¥Progressive Business Publications .

Prior to Investigation  Know the policy for accident investigation ± What are the sequence of procedures? ± Who should be informed? ± What triggers an investigation? ± What are the reporting requirements?  Know responsibilities of investigators  Know required paperwork ± Accident reports. witness statements. etc. ± Who receives what? Copyright ¥Progressive Business Publications .

Conducting the Investigation  Keep all notes and records in bound notebook or 3-ring binder  Record and make documented observation on ± Pre-accident conditions ± Accident sequence ± Post-accident conditions  Document victim locations. witnesses. energy sources and other contributing factors Copyright ¥Progressive Business Publications . machinery.

Accident Scene  Control the scene ± Get medical attention for the injured ± Inspect scene for other hazards and eliminate them ± Keep everyone away from scene ± Prevent removal of evidence or change of conditions  Document scene before changes are made ± Take photos ± Draw scaled sketches ± Record measurements Copyright ¥Progressive Business Publications .

Interview Witnesses  Get preliminary statements as soon as possible  Put witnesses at ease ± Explain purpose of investigation and be courteous and polite  Word questions carefully and be sure witnesses understand what¶s being asked  Take notes ± Record exact words ± Only use a tape recorder with witness¶ permission  Supply each witness with a copy of his or her statements Copyright ¥Progressive Business Publications .

) Copyright ¥Progressive Business Publications .Questions for Witnesses  What did you see?  What did you hear?  Where were you standing/sitting? ± Use sketches and diagrams to help witness  Was there anything different today?  What do you think caused the accident?  Basic information: qualification of each witness (name. occupation. etc. address. years experience.

Questions for Supervisors  What is the normal procedure for activities involved in the accident?  What was different?  What type of training did persons involved in the accident have?  What do you think caused the accident?  What do you think could have prevented the accident? Copyright ¥Progressive Business Publications .

opinion Copyright ¥Progressive Business Publications .Watch for the Pitfalls  Bias  Perspective  Embellishment  Trauma  Fact v.

Background Records  Maintenance records  Inspection records  Copies of policies     and procedures Accident reports for similar incidents Training records Production schedules Process diagrams Copyright ¥Progressive Business Publications .

Analyze the Data  Gather all photos. drawings. interview material and other information  Determine a clear picture of what happened ± Determine the specified work procedure ± Include work and environmental conditions at the time of the accident ± Formally document the sequence of events ± Immediate actions taken at the scene ± Injuries to personnel and damage to property Copyright ¥Progressive Business Publications .

when and to what extent? ± What were the distinctive features of the change?  List all possible causes  Select the most likely causes Copyright ¥Progressive Business Publications . locate and describe the change ± What was and was not affected? ± Where.Change Analysis  Define the problem ± what happened?  Establish the norm ± what should have happened?  Identify.

Job Safety Analysis  Break job into basic steps ± Identify hazards associated with each step ± Identify prescribed controls for each hazard  Review JSA if one is available for job involved in the accident  Perform JSA if one is not available to determine the events and conditions that led to the accident Copyright ¥Progressive Business Publications .

The Causes of Accidents ACCIDENT ACCIDENT Personal Injury Property Damage DIRECT Causes Unplanned Release of Energy and/or Hazardous Material INDIRECT Causes (Symptoms) BASIC Causes Unsafe Act Unsafe Condition Management Safety Policies & Decisions Personnel Factors Environmental Factors Copyright ¥Progressive Business Publications .

Examples of Basic Causes  Lack of safe job procedures  Inadequate training  Failure to establish and enforce safety rules  Tolerance of unsafe conditions  Inadequate design or layout  Inadequate inspection program  Inadequate preventive maintenance program  Inadequate safety standards for purchases Copyright ¥Progressive Business Publications .

Examples of Unsafe Conditions  Inadequate guarding  Defective equipment  Hazardous arrangement     or procedure Unsafe design or construction Improper illumination Improper ventilation Unsafe dress or apparel Copyright ¥Progressive Business Publications .

mixing. combining  Failing to secure or warn  Taking unsafe position or posture  Failing to use PPE  Horseplay Copyright ¥Progressive Business Publications .Examples of Unsafe Acts  Operating without authority  Operating at unsafe speed  Disabling safety devices  Unsafe loading.

Accident Report  Background information ± Where and when accident occurred? ± Who and what were involved?  Account of the accident ± how did it happen? ± Sequence of events ± Extent of injury/damage  Discussion/Analysis of causes ± why did it occur? ± Avoid blaming a single worker or cause ± Dig deep Copyright ¥Progressive Business Publications .

Report Recommendations  Recommendations for prevention ± Analyze in tandem with causes ± List corrective actions to ³foolproof´ activity  Examples: ± Repairing or replacing unsafe condition ± Redesigning process ± Re-training workers ± Drafting a new safety procedure ± Undertaking disciplinary actions Copyright ¥Progressive Business Publications .

File Report  File a copy of the report with appropriate individuals  File all supporting data (photos. etc. interview notes.) Copyright ¥Progressive Business Publications .

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