Accident / Incident

Investigation
Prepared by:
Aldrin B. Lopez, CIE, AAE, RSO
 Why Report?
O To be able to make an analysis of the
incident
O To avoid unsafe act and unsafe
condition.
O To break the chain of eents
 Accidents that Should Be
Reported
O Five consecutive first aid cases per
week
O Medical treatment cases
O Lost work cases
O Fatality
O Property Damage
O Environmental Damage
O Near misses
 Rule 050 Section 1051
Definitions
O Medical Treatment Injury an injury which
does not result in a disabling injury but which
requires first aid and medical treatment of
any kind.
O Disabling Injury a work injury which results
in death, PTD, PP or TTD.
O Permanent Total Disability an injury or
sickness other than death which permanently
and totally incapacitate an employee from
engaging in any gainful occupation which
results in the lost or complete loss of use of
any of the body parts.
 Rule 050 Section 1051
Definitions
O Permanent Partial Disability an injury
other than death or PTD which results in
the loss of loss with use of any member
or part of a body regardless of any pre
existing disability of the injured member
or impaired body function.
O Temporary Total Disability an injury or
illness which does not result in death or
PTD, PPD but which results in disability
of the from work for a day or more.
 Rule 050 Section 1051
Definitions
O Days of Disability any day which an
employee is unable, because of injury or
illness to perform effectively throughout
a full shift the essential functions of a
regularly established job which is open
and available to him.
O Total Days Lost Combined total of all
injuries or illness due to TTD
injuries/illness or scheduled charges to a
fatality, PTD, PPD.
 Rule 050 Section 1051
Definitions
O Exposure The total number of
employee hours worked by all
employees of the reporting
establishments or units including
overtime.
O Disability Injury Frequency Rate
Number of disabling injury per
1,000,000 employees hours of exposure
rounded to nearest 2 decimal places.
 Rule 050 Section 1051
Definitions
O Lost Time Incident Any occupational
injury or illness that result in an
employee being unable to return to full
duty on the next day. Fatality not
recognized as Lost Time Incident.
O Lost Time Incident Rate = number of LTI x
2000,000 / number of man hours worked.
O Total Recordable Incident Rate = number
of recordable incident x 200,000 /
number of man hours worked.
 TYPES OF ACCIDENT
Personal Injury or Illness and Deviation
Factors regarding the physical aspects
Property Damage
Combination of personal injury and property
damage
Near miss incident
 Accident Categories
O Serious Accidents
O Non Serious Accidents
Roles and Responsibilities
O Department
O Ensure accidents involving their operations or
workers are investigated.
O Ensure corrective actions are taken.
O Supervisors
O Participate in incident investigation
O Take corrective actions
O EHS
O Investigate incidents promptly and thoroughly
O Issue accident investigation report.
O Provide training in investigation methods and
techniques when requested.
 What is an Incident?
O Incident is an undesired event that has or
could result in harm to people,
environment, damage to property or
assets or a breach of security.
O Near miss It is an incident with negligible
actual consequences, but with potential for
harm / illness or damage / loss, pollution or
combination of all.
O Accident It is an incident which results in
actual injury / illness and / loss or damage/
to environment to material / production.
 Overview
O Purpose of Investigation
O Managing the Accident Scene
O Steps in Conducting Investigation
 Purpose
O Investigation are conducted to:
O Prevent reoccurrence
O Comply with polices and regulatory
requirements
O Maintain employee awareness
 Accidents are result of

O Unsafe Act Behaviors which could

permit the occurrence of an accident
or incident.

O Unsafe Conditions Circumstances

which could permit the occurrence of
an accident or incident.
 Prevention is the reason for
conducting an Accident Investigation
Unless the unsafe acts/conditions
OIdentified
OEliminated or controlled
 All accidents must be
investigated:
O LTI
O Non LTI
O Near Miss
O Chemical Spill
O Property Damage
O Fire and Eplosion
 Advantages of Supervisors
Over Other Investigators
O More familiar with the people
involved
O Better understanding of the
operations
O Personal interest in investigations
Managing the Accident Scene
O Two Priorities
O Care & Treatment of the injured
O Elimination or control of remaining
hazards
 Care & Treatment of the
injured
O Supervisors can increase their ability
to respond to Medical Emergencies
by:
O Training in First Aid
O Drills under normal and abnormal
condition
O Liaison with hospitals
 Controlling Remaining
Hazards
If a hazardous environment or toxic
materials exist:
Notify necessary personnel
Provide PPE to potentially exposed
Refer to SDS
 Controlling Remaining
Hazards
Isolate the Site
To protect people from further injury
To preserve evidence and valuable clues
Successful Investigation is done .
Immediately
Completely
Thoroughly
Investigate immediately, because
Operations are disrupted
Memories Fade
Employee are at risk
 Investigation Strategy
O Gather Information
O Search for & Establish facts
O Isolate essential contributing factors
O Find root Causes
O Determine corrective actions
O Implement corrective actions
 Secure the Scene
O Eliminate the hazards
O Control Chemicals
O De energize
O De pressurize
Accident Reports Remedial
Action
General report form contents.
OLocation
OTime of occurrence
OIdentification of primary people involved
ODescription of Accident
OType of accident/ incident
OAnalysis of Causes
OEvaluation of potentially severity and
frequency
ORemedial action plan for prevention
OFollow up action plan
 Reports should be
O Clear

O Detailed

O Neat

O Legible
Investigative Procedures
1. Define the scope of the investigation.
2. Select the investigators. Assign specific
tasks to each (preferably in writing).
3. Present a preliminary briefing to the
investigating team, including:
a. Description of the accident, with
damage estimates.
b. Normal operating procedures.
c. Maps (local and general). d. Location
of the accident sit
Investigative Procedures
e. List of witnesses.
f. Events that preceded the accident.
4. Visit the accident site to get updated
information.
5. Inspect the accident site.
a. Secure the area. Do not disturb the scene
unless a hazard exists.
b. Prepare the necessary sketches and
photographs. Label each carefully and keep
accurate records.
6. Interview each victim and witness. Also interview
those who were present before the accident and
those who arrived at the site shortly after the
accident. Keep accurate records of each interview.
Use a tape recorder if desired and if approved.
Investigative Procedures
7. Determine
a. What was not normal before
the accident.
b. Where the abnormality
occurred.
c. When it was first noted.
d. How it occurred
Investigative Procedures
8. Analyze the data obtained in step 7.
Repeat any of the prior steps, if necessary.
9. Determine
a. Why the accident occurred.
b. A likely sequence of events and
probable causes (direct, indirect, basic).
c. Alternative sequences.
10. Check each sequence against the data
from step 7.
11. Determine the most likely sequence of
events and the most probable causes.
Investigative Procedures
12. Conduct a post-investigation
briefing.
13. Prepare a summary report,
including the recommended actions to
prevent a recurrence. Distribute the
report according to applicable
instructions.
 Fact Finding
o Gather evidence from many sources during
an investigation.
o Get information from witnesses and
reports as well as by observation.
o Interview witnesses as soon as possible
after an accident.
o Inspect the accident site before any
changes occur.
o Make photographs and sketches of the
accident scene. Record all pertinent data on
maps.
 Fact Finding
o Get copies of all reports. Documents
containing normal operating procedures,
flow diagrams, maintenance charts, or
reports of difficulties or abnormalities are
particularly useful.
o Keep complete and accurate notes in a
bound notebook.
o Record pre-accident conditions, the accident
sequence, and post-accident conditions. In
addition, document the location of victims,
witnesses, machinery, energy sources, and
hazardous materials.
 Fact Finding
o Include laws in the notes taken during
the investigation or in the later analysis
of data.
o In addition, gather data during the
investigation that may lend itself to
analysis
by these laws, principles, or properties.
o An appendix in the final report can
include an extended discussion.
 Interviews
1. Appoint a speaker for the group.
2. Get preliminary statements as soon as
possible from all witnesses.
3. Locate the position of each witness on a
master chart (including the direction of view).
4. Arrange for a convenient time and place to
talk to each witness.
5. Explain the purpose of the investigation
(accident prevention) and put each witness
at ease.
 Interviews
6. Listen, let each witness speak freely, and be
courteous and considerate.
7. Take notes without distracting the witness. Use
a tape recorder only with consent of the
witness.
8. Use sketches and diagrams to help the
witness.
9. Emphasize areas of direct observation. Label
hearsay accordingly.
10. Be sincere and do not argue with the witness.
 Interviews
11. Record the exact words used by the witness
to describe each observation. Do not "put
words into a witness' mouth."
12. Word each question carefully and be sure the
witness understands.
13. Identify the qualifications of each witness
(name, address, occupation, years of
experience,
etc.).
14. Supply each witness with a copy of his or her
statements. Signed statements are desirable
 Type of Witnesses
O Extroverts will appear very convincing
witnesses. But Their evidence may be as
correct as it appears.
O Introverts will appear as poor witness.
Interviewing them may seem as waste of
time, but they might have the most
important information.
O Suspicious Will be reluctant to get
involve. They hate publicity, guard their
privacy and resent being questioned.
 Type of Witnesses
O Illiterate may appear timid and
hesitant to cover their illiteracy.
O Prejudiced are psychologically ill
suited to give testimony.
O Intoxicated should be listened to, but
re interviewed in full when sober.
O Juvenile Can give very objective
evidence.
O Excitable
 Type of Witnesses
Know nothing Are the ones identified
as prime witnesses who insist they do
not know and did not see anything.
Devious may distort their testimonies
to avoid personal implication or
unfavorable reflection on an associate.
Injured Should generally not be
questioned until after they have
received medical treatment.
 PROBLEM SOLVING
TECHNIQUES
The Scientific Method
The scientific method forms the
basis of nearly all problem solving
techniques. It is used for conducting
research. In its simplest form, it
involves the following sequence:
making observations, developing
hypotheses, and testing the
hypotheses.
 PROBLEM SOLVING
TECHNIQUES
As with scientific research, the most
difficult part of any investigation is the
formulation of
worthwhile hypotheses. Use the following
three principles to simplify this step:
1.The principle of agreement.
An investigator uses this principle
to find one factor that associates with
each observation
 PROBLEM SOLVING
TECHNIQUES
The principle of differences.
This principle is based on the idea
that variations in observations are due only
to differences in
one or more factors.
The principle of concomitant variation.
This principle is the most important
because it combines the ideas of both of
the preceding principles. In using this
principle, the investigator is interested in
the factors that are common as well as
those that are different in the observations.
 PROBLEM SOLVING
TECHNIQUES
O Change Analysis - this technique
emphasizes change.
O Gantt charts are sequence diagrams.
Use them for scheduling investigative
procedures. They can also aid in the
development of the most probable
sequence of events that led to the
accident. Such a chart is especially
useful in depicting events that occurred
simultaneously.
 PROBLEM SOLVING
TECHNIQUES
O Job Safety Analysis
Job safety analysis (JSA) is part of
many existing accident prevention
programs. In general, JSA breaks a job
into basic steps, and identifies the
hazards associated with each step.
The JSA also prescribes controls for
each hazard. A JSA is a chart listing
these steps, hazards, and controls.
 PROBLEM SOLVING
TECHNIQUES
O Failure Mode and Effect Analysis
Failure mode and effect analysis
(FMEA) determines where failures
occurred. Consider all items used in
the task involved in the accident.
These items include people,
equipment, machine parts,materials,
 PROBLEM SOLVING
TECHNIQUES
O Fault Tree Analysis
Fault tree analysis (FTA) is a logic
diagram. It shows all the potential
causes of an accident or other
undesired event.
 Report of Investigation
1. Background Information

a. Where and when the accident

occurred
b. Who and what were involved
c. Operating personnel and other
witnesses
 Report of Investigation
2. Account of the Accident (What
happened?)
a. Sequence of events
b. Extent of damage
c. Accident type
d. Agency or source (of energy or
hazardous material)
 Report of Investigation
Discussion (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)
 Report of Investigation
Recommendations (to prevent a
recurrence) for immediate and long-
range action to remedy:
a.Basic causes
b.Indirect causes
c.Direct causes (such as reduced
quantities or protective equipment or
structures)
End of Presentation