powerpoint presentation accident investigation

Accident Investigation

Nov 08, 2014

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HU151_Lect 9. Accident Investigation. Fall 2012/13. OUTLINE. Accident/Incident Investigation Outcome Investigation Steps Three Types of Causes Example. What Is An Accident?.

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• accident prevention
• energy sources
• accident investigation
• accident prevention program
• energy sources hazardous materials

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HU151_Lect 9 Accident Investigation Fall 2012/13

OUTLINE • Accident/Incident • Investigation Outcome • Investigation Steps • Three Types of Causes • Example HU 151, Lecture9, Accident Investigation

What Is An Accident? An unplanned, unwanted, but controllable event which disrupts the work process and causes personal injury and/or in property damage. HU 151, Lecture9, Accident Investigation

According to BP's September 2010 report, the accident started with a "well integrity failure". This was followed by a loss of control of the pressure of the fluid in the well. The "blowout preventer", a device which should automatically seal the well in the event of such a loss of control, failed to engage. Hydrocarbons shot up the well at an uncontrollable rate and ignited, causing a series of explosions on the rig. BP's Deepwater Horizon oil well explosion last year - killed 11 workers and caused the biggest offshore spill in US history. http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf HU 151, Lecture9, Accident Investigation

What Is An Incident? An unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property. HU 151, Lecture9, Accident Investigation

Incident Investigation Incidents should be investigated as well, since they are potential “accidents”. • Criteria for investigating an incident: • What is reasonably the worst outcome, equipment damage, or injury to the worker? • What might the severity of the worst outcome have been? • If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an accident investigation. HU 151, Lecture9, Accident Investigation

Accident Investigation • Will determine how and why of failures. • Examine possible corrective action. • Aid in the accident prevention and elimination of a clearly identified hazard. • Most important -Investigation is not intended to place blame. HU 151, Lecture9, Accident Investigation

Investigation Outcome 1. Prevent future incidents (leading to accidents). 2. Identify and eliminate hazards. 3. Expose deficiencies in process and/or equipment. 4. Reduce injury and worker compensation costs. 5. Maintain workers’ morale. 6. Meet regulations. HU 151, Lecture9, Accident Investigation

Main Steps 1. Develop a plan 2. Assemble an investigation kit 3. Investigate all incidents and accidents immediately 4. Collect facts 5. Interview witnesses 6. Write a report HU 151, Lecture9, Accident Investigation

Begin Investigation Immediately It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget. HU 151, Lecture9, Accident Investigation

CAUSES • Direct Cause – the actual energy (movement or source) that caused injury to employee. If this energy wasn’t present, the injury would not have occurred. • Indirect Causes – any unsafe acts or conditions that contribute to the injury occurring. • Basic Causes – policies, procedures, environment or personal factors that contribute to the injury occurring. HU 151, Lecture9, Accident Investigation

The Three Basic Causes Poor Management Safety Policy & Decisions Personal Factors Environmental Factors Basic Causes ACCIDENT Personal Injury Property Damage Unsafe Condition Unsafe Act Indirect Causes Unplanned release of energy and/or Hazardous material Direct Causes HU 151, Lecture9, Accident Investigation

Preparing for the Investigation • Develop contingency plans prior to the accident. • Designate an investigator • This person should only be responsible for investigating. • Should have a good working knowledge of operating procedures. • Be equipped with the right tools to do the job thoroughly. HU 151, Lecture9, Accident Investigation

Record the Facts • Interview witnesses as soon as possible. • Document the accident scene before any changes are made. • Take photos • Draw scaled sketches • Record measurements • Gather support documents such as maintenance records, reports, production schedules or process diagrams. HU 151, Lecture9, Accident Investigation

Record the Facts • Keep all notes and remarks in a bound notebook or three ring binder. • Record: • Pre-accident conditions • Accident sequence • Post-accident conditions • Document victim location, witnesses, machinery, energy sources and other contributing factors. HU 151, Lecture9, Accident Investigation

Record the Facts • Even the most insignificant detail may be useful. • Document and then document some more. • The investigator should be concentrating solely on the investigation at hand. HU 151, Lecture9, Accident Investigation

Interviewing • Excellent source of first hand knowledge. • May present pitfalls in the form of: • Bias • Perception • Exaggeration • It is important to maintain a clear thought process and control of the interview. HU 151, Lecture9, Accident Investigation

Interviewing • Get preliminary statements as soon as possible from all witnesses. • Locate the position of each witness on a master chart (including the direction of view) • Explain the purpose of the investigation (accident prevention) and put each witness at ease. HU 151, Lecture9, Accident Investigation

Interviewing • Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness). • Use sketches and diagrams to help the witness. • Emphasize areas of direct observation and label hearsay accordingly. • Record the exact words used by the witness to describe each observation. HU 151, Lecture9, Accident Investigation

Interviewing • Word each question carefully and be sure the witness understands. • Identify the qualifications of each witness (name, address, occupation, years of experience, etc.). • Supply each witness with a copy of their statements (signed statements are desirable). HU 151, Lecture9, Accident Investigation

Problem Solving TechniquesChange Analysis • This technique emphasizes change to correct the problem. • Examination of deviations from the norm are scrutinized. • Consider all problems to result from some unanticipated change. • Analyze the changes to determine its cause. HU 151, Lecture9, Accident Investigation

Problem Solving TechniquesChange Analysis • Use the following steps in this method: • Define the problem (What happened?). • Establish the norm (What should have happened?). • Identify, locate, and describe the change (What, where, when, to what extent). • Specify what was and what was not affected. • Identify the distinctive features of the change. • List the possible causes. • Select the most likely causes. HU 151, Lecture9, Accident Investigation

Problem Solving TechniquesJob 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 as well as prescribing controls for each hazard. • A JSA is a chart listing these steps, hazards, and controls. • Review the JSA during the investigation if a JSA has been conducted for the job involved in an accident. • Perform a JSA if one is not available to determine the events and conditions that led to the accident. HU 151, Lecture9, Accident Investigation

Problem Solving TechniquesJob Safety Analysis HU 151, Lecture9, Accident Investigation

Investigation Report • An accident investigation is not complete until a report is prepared and submitted to the proper authorities. • Suggestion of items to include in your report. HU 151, Lecture9, Accident Investigation

Investigation Report • Background Information • Where and when the accident occurred • Who and what were involved • Operating personnel and other witnesses • Account of the Accident (What happened?) • Sequence of events • Extent of damage • Accident type • Agency or source (of energy or hazardous material) HU 151, Lecture9, Accident Investigation

Investigation Report • Discussion (Analysis of the Accident - HOW; WHY) • Direct causes (energy sources; hazardous materials) • Indirect causes (unsafe acts and conditions) • Basic causes (management policies; personal or environmental factors) HU 151, Lecture9, Accident Investigation

Investigation Report • Recommendations (to prevent a recurrence) for immediate and long-range action to remedy: • Basic causes • Indirect causes • Direct causes (such as reduced quantities or protective equipment or structures) HU 151, Lecture9, Accident Investigation

CASE STUDY - Bus Accident Description: “I was checking the steering fluid in bus engine. I had to climb up on the front tire and when I was getting down, I felt my left knee pop.” HU 151, Lecture9, Accident Investigation

Why did employee have to stand on the tire? Are there other ways of checking fluids? What is the process for getting down? What type of training did you receive for checking fluids? By who? What is the distance between tire and first step to get down? Each additional step? Tell me what you did from the time you arrived at work? What was going on/happening around you at the time you were getting down? What type of shoes were you wearing? Have there been similar incidents? Explain. What was the weather? QUESTIONS TO UNCOVER CAUSES HU 151, Lecture9, Accident Investigation

Driver was not trained how to check fluids on this type of bus. There are two step ladders available, but none close by. No process or procedures in place for checking fluids. Ladder use is covered in Accident Prevention Program but there was no training specific to ladder use provided to drivers. Distance from tire to the peg step is 90 cm, step to ground is 50 cm. Driver had washed bus prior to checking fluids and area around the bus was still wet. Shoes being worn did not have good tread on soles to prevent slipping. Another driver came up and started talking as driver was getting down. Investigation Findings – Bus HU 151, Lecture9, Accident Investigation

Accident Causes – Bus Direct causes Improper body movement Indirect causes Failure to use proper equipment - step ladder Wearing inappropriate footwear Lack of step ladders available and not close by Employee was distracted Basic causes Inadequate training in pre-trip procedures for all types of buses No designated bus wash area HU 151, Lecture9, Accident Investigation

CORRECTIVE ACTION PLAN HU 151, Lecture9, Accident Investigation

? HU 151, Lecture9, Accident Investigation

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Occupational Safety and Health Administration

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Incident Investigation

Investigating a worksite incident, additional resources.

• Workers' Rights

OSHA strongly encourages employers to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called "near misses"), in which a worker might have been hurt if the circumstances had been slightly different.

In the past, the term "accident" was often used when referring to an unplanned, unwanted event. To many, "accident" suggests an event that was random, and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA suggests using the term "incident" investigation.

Investigating a worksite incident- a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer's commitment to a safe and healthful workplace.

Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding and perspectives to the investigation.

In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.

For example:

• If a procedure or safety rule was not followed, why was the procedure or rule not followed?
• Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety?
• Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?

These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedural, training, and other safety and health program deficiencie.

Addressing underlying or root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate serious consequences from similar future incidents.

To assist employers and workers in conducting effective incident investigations, and to develop corrective action plans, the following resources can help:

• OSHA Fact Sheet. Root Cause: The Importance of Root Cause Analysis During Incident Investigation .(2016). This fact sheet provides guidance for identifying root causes of incidents and/or near misses in order to prevent their recurrence.
• OSHA. Incident [Accident] Investigations: A Guide for Employers . (2015). This guidance document provides employers with a systems approach to identifying and controlling the underlying or root causes of all incidents in order to prevent their recurrence.
• National Safety Council. How to conduct an incident investigation . (2014). This four-page guidance document, developed by the OSHA/NSC National Alliance , provides brief guidance on conducting an incident investigation.
• Washington State Department of Labor & Industries. Accident Investigation Basics . (2009). This PowerPoint-based online training module provides an overview on conducting root-cause workplace incident investigations.