Accident Investigation tools and techniques

This presentation aims to help organizations to investigate over accidents to avoid reoccurrence

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Accident Investigation

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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

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Consequences of Accidents
 Direct Consequences
– Personal injury
– Property loss
 Indirect Consequences
– Lost income
– Medical expenses
– Lowered morale
– Training replacements
– Lost productivity

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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

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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?

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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,
machinery, energy sources and other
contributing factors

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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

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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

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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, address, occupation, years
experience, etc.)

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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?

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Watch for the Pitfalls
Bias
Perspective
Embellishment
Trauma
Fact v. opinion

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Background Records
Maintenance records
Inspection records
Copies of policies
and procedures
Accident reports
for similar incidents
Training records
Production schedules
Process diagrams

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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

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Change Analysis
Define the problem – what happened?
Establish the norm – what should have
happened?
Identify, locate and describe the change
–What was and was not affected?
–Where, when and to what extent?
–What were the distinctive features of the change?
List all possible causes
Select the most likely causes

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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

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

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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

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Examples of Unsafe Conditions
Inadequate guarding
Defective equipment
Hazardous arrangement
or procedure
Unsafe design or
construction
Improper illumination
Improper ventilation
Unsafe dress or apparel

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Examples of Unsafe Acts
Operating without authority
Operating at unsafe speed
Disabling safety devices
Unsafe loading, mixing, combining
Failing to secure or warn
Taking unsafe position or posture
Failing to use PPE
Horseplay

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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

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Report Recommendations
Recommendations for prevention
–Analyze in tandem with causes
–List corrective actions to “foolproof” activity
Examples:
–Repairing or replacing unsafe condition
–Redesigning process
–Re-training workers
–Drafting a new safety procedure
–Undertaking disciplinary actions

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File Report
File a copy of the
report with appropriate
individuals
File all supporting data
(photos, interview
notes, etc.)