Accident Investigation

Massachusetts Manufacturing Self-Insurance Group, Inc.

Safety Awareness For Everyone from Cove Risk Services

What is an Accident?

• An unintended happening, mishap

• Most often an accident is any unplanned event that results in personal injury or in property damage

• The failure of people, equipment, supplies or surroundings to behave or react as expected

Accident Investigation

• Will determine the “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

Be Prepared

• Designate an investigator (or a team)– This should be one of this persons key

responsibilities– Should have a good working knowledge of

operating procedures

• Be equipped with the right tools to do the job thoroughly

Record the Facts

• Interview witnesses as soon as possible

• Record all necessary information at the accident scene before any changes are made– Take photos (camera or camera phone)– Record measurements

• Gather support documents such as maintenance records, employee records, production schedules, training documents and records, or process diagrams

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, equipment, machinery, energy sources and other contributing factors

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

Interviewing

• Excellent source of first hand knowledge

• May present pitfalls in the form of:– Bias– Perspective– Embellishment

• It is important to maintain a clear thought process and control of the interview

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.

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

Interviewing

• Word each question carefully and be sure the witness understands

• Identify the qualifications of each witness (name, address, occupation, years of experience, etc.)

• If they wish, supply each witness with a copy of their statements (signed statements are desirable)

Problem Solving Techniques

• This technique emphasizes change to correct the problem

• Examine the differences between the norm and what actually happened

• Consider all problems to result from some unanticipated change

• Analyze the changes to determine its cause

• 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 affected

– Identify the distinctive features of the change

– List the possible causes

– Select the most likely causes

Problem Solving TechniquesChange Analysis

Problem Solving TechniquesJob Hazard Analysis

• Job Hazard Analysis (JHA) is part of many existing accident prevention programs

• In general, JHA breaks a job into basic steps, and identifies the hazards associated with each step as well as prescribing controls for each hazard

• A JHA is a chart listing these steps, hazards, and controls

• Review the JHA during the investigation if a JHA has been conducted for the job involved in an accident

• Perform a JHA if one is not available to determine the events and conditions that led to the accident

Investigation Report

• An accident investigation is not complete until a report is prepared and submitted to the proper managers

Investigation Report• Background Information

– Where and when the accident occurred – Who and what were involved – Personnel and other witnesses

• Account of the Accident (What happened?)

– Sequence of events – Extent of injury– Accident type – Source

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)

Investigation Report

• Recommendations (to prevent a recurrence)

for immediate and long-term corrective actions

– Engineering Controls

– Administrative Controls

– PPE

Accident Scenario

Joe, the maintenance worker, strained his knee after slipping and falling.

What questions need answering?

Some Questions• Where did this happen? What time of year is it (is this normal)? What time/shift? Was he the first person to go through this area and walk on this surface?

• What kind of floor is this? When was it last inspected for slip hazards? What are the normal inspection and maintenance procedures? Does this current procedure make sense?

• Was he trained to look for hazards like this? If yes, when? Is the training effective? Why or why not? Were there wet floor or other warning signs?

• Who is the supervisor? Are there other outside work factors that may have lead to this?

• Is there a carpet? Is it long enough? Is it of the appropriate quality? What kind of shoes does he wear?

• Is disciplinary action necessary? For him or anyone else?

• Are new procedures necessary?

Potential Corrective Actions• Develop a policy and procedure for inspecting and maintaining the floor at all employee entrances.

• Provide a runner carpet of the correct length (one that will extend far enough to capture all moisture). Provide more wet floor signs.

• Re-train staff on all slip hazards, including at entrances. Educate them on the importance of reporting hazards and wearing appropriate footwear when entering the building.

• Implement a slip-resistant footwear policy.

• Inform employees on measures taken to reduce future recurrence of this type of accident.

• Improve awareness for all staff via posters, mailers, handouts, etc. as to hazards and what the new procedures are.

• Praise employees for following expected procedure as trained.

• Counsel employees who fail to act as expected after receiving education (not identifying hazards, not wearing the correct footwear). Document this action.

• Inform Supervisors and Managers that incidents that occur as a result of low competence will effect their performance review.

Any Questions

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Massachusetts Manufacturing Self-Insurance Group, Inc.

Safety Awareness For Everyone from Cove Risk Services