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Accident Investigation Accident Investigation Techniques and ReportingTechniques and Reporting
For
NERI Safety Coordinators
Presented By:
Bill Hettrick
May 23, 2007
Accident InvestigationAccident InvestigationWorkshopWorkshop
Why investigate accidents?Investigation ProcessRoot Cause & Contributing Causes
– Methods Supervision, Policies, Procedures, Rules
– Equipment Materials, Safeguards, Product, Machinery
– Environment Facilities, Heat/Cold, Agents, Atmosphere
– Personnel Training, Fatigue, Protection, Fitness
Corrective Action
Response
Fact-Finding
Analysis
Follow-Up
ACCIDENT INVESTIGATION
THE PRIMARY PURPOSE OF ACCIDENT INVESTIGATION IS TO DETERMINE THE ROOT CAUSES OF ACCIDENTS, SO THAT STEPS CAN BE TAKEN TO REMOVE THESE CAUSES AND PREVENT RECURRENCE OF SIMILAR EVENTS
REPORTING EVALUATING ANALYZING
WHY DO ACCIDENTS OCCUR?WHY DO ACCIDENTS OCCUR? SUPERVISION POLICES
METHODS
PROCEDURES RULES
FACILITIES HEAT/COLD
ENVIRONMENT
AGENTS ATMOSPHERE
MATERIAL SAFEGUARDS
EQUIPMENT
PRODUCT MACHINERY
TRAINING FATIGUE
PERSONNEL
PROTECTION FITNESS
ACCIDENT INPUT OUTPUT
SYSTEM FAULTS
SYSTEM FAULTS
SYSTEM FAULTS
SYSTEM FAULTS
Definition of TermsDefinition of Terms
Incident – A deviation from an acceptable standard
Hazard – An incident without adequate controls
Accident – When the potential of a hazard results in damage
All Accidents come from incidents, but not all incidents result in accidents
90% of all Accidents Result 90% of all Accidents Result from Human Factorsfrom Human Factors
Unsafe Condition
Any condition of tools,
equipment or other
elements in an
employee’s work
environment that may
cause or contribute to
an accident.
Unsafe ActAny hazard created
as a result of a
human action or
behavior
Examples of Unsafe ActsExamples of Unsafe Acts
Lack of adequate training
Poor attitude/behavior Lack of required PPE Working outside of
normal operating procedures
Unclear safety rules Unclear polices and
procedures Poor management
and/or supervision
Additional Benefits of a Good Additional Benefits of a Good InvestigationInvestigation
Demonstrates concern for fellow workers May identify other similar unsafe acts or
conditions Reduces operating costs
The Injured EmployeeThe Injured Employee
Death Pain & suffering Permanent disability Effects on family Loss of earning Inability to resume
occupation Psychological effects Feeling of uselessness Social effects Loss of personal activities
Effects on the SupervisorEffects on the Supervisor
Loss of a trained worker Loss of production Extra work for others Investigations and reports Training a new worker Could I have prevented it? Stress Can’t get job done on time
Three Types of Accident Three Types of Accident CausesCauses
Immediate Cause(s)
Contributing Cause(s)
Root Cause(s)
Immediate CausesImmediate Causes
The unsafe act or condition
Struck against Fall on same level Fall from different
level Caught between Electricity Equipment Material handling
Contributing CausesContributing Causes
Not Following
Standard Practices
Proper use of tools & equipment
Use of PPE Correct lifting Safe work practices Safety policy and
procedures Use of monitor
Not ProvidingStandard Conditions
Adequate warning systems
Equipment in good condition
Good housekeeping Proper guardrail
systems Appropriate fall
protection
Root CausesRoot Causes The origin of the immediate and contributing
causes
Must be eliminated and or controlled to prevent recurrence
Examples of Root CausesExamples of Root Causes Personal Factors
• Lack of knowledge or skill
• Improper motivation• Unfit for job• Lack of training
Job Factors• Unsafe equipment• Inadequate safety
standards• Housekeeping issues• Improper job set-up
Management & Supervision• Inadequate instructions• Lack of enforcement• Safety program not
followed• Hazards not corrected
The Following Statements are The Following Statements are NOT Proper NOT Proper RootRoot Causes Causes
Didn’t pay attention Was careless Poor housekeeping Didn’t climb ladder correctly Bad luck Stupid No cause
These causes are too general no constructive measures were taken
Round Robin Round Robin Accident Investigation Accident Investigation
Accident InvestigationAccident InvestigationCase StudyCase Study
Describe in detail, how the incident occurred and what part of the body it affected:– Employee fractured left foot. Employee slipped while climbing up
ladder.
Describe the root causes and how they contributed to this accident:– Employee failed to maintain three points of contact.
What should be done, and by whom to prevent recurrence of this type of incident in the future:– Employee should be more careful while on ladders.
Accident InvestigationAccident InvestigationCase StudyCase Study
Describe in detail, how the incident occurred and what part of the body it affected:– Employee sustained burns to hands and face while filling the hot
lugger for the fill pipe.
Describe the root causes and how they contributed to this accident:
– Employee failed to wear proper clothing and PPE while working with hot materials.
What should be done, and by whom to prevent recurrence of this type of incident in the future:– Face shields should be placed near fill-pipe.
Accident InvestigationAccident InvestigationCase StudyCase Study
Describe in detail, how the incident occurred and what part of the body it affected:– 65 year-old male struck in the head and neck from debris that blew
off the scaffold system. Claimant was walking across the parking area at time of accident.
Describe the root causes and how they contributed to this accident:– Foreman did not secure debris against high winds.
What should be done, and by whom to prevent recurrence of this type of incident in the future:– Crew should review housekeeping practices and weather forecasts.
Accident InvestigationAccident InvestigationCase StudyCase Study
Describe in detail, how the incident occurred and what part of the body it affected:– While traveling back from the jobsite, the foreman was involved in
a three vehicle accident. Pete, who was sitting in the passenger seat sustained a neck strain.
Describe the root causes and how they contributed to this accident:
– Driver was not at fault – no further actions required.
What should be done, and by whom to prevent recurrence of this type of incident in the future: None
Accident InvestigationAccident InvestigationCase StudyCase Study
Describe in detail, how the incident occurred and what part of the body it affected:– Employee was carrying 5-gallon buckets of bonding adhesive from the
loading area to the work area. Employee claims he felt soreness in his back two days later.
Describe the root causes and how they contributed to this accident:
– No specific incident event identified. Employee may have tried to hurry to move buckets without using proper body mechanics.
What should be done, and by whom to prevent recurrence of this type of incident in the future:
– Employees should be reminded to lift with their legs, keep stomach tight, and inspect their path of travel.
A Complete Investigation A Complete Investigation Includes:Includes:
All factsAll opinionsWitness statementsJob site observationsReview of policies and proceduresReview of training records
Why the Superintendent and/or Why the Superintendent and/or Foreman are the Key Professionals Foreman are the Key Professionals to Conduct Accident Investigationsto Conduct Accident Investigations
They knows the job requirements and expectations
They knows their fellow co-workers
The Supervisor’s RoleThe Supervisor’s Role
The Supervisor’s attitude determines the success of the investigation and the employee’s return to work experience ……..
How to Complete the How to Complete the Accident Investigation ReportAccident Investigation Report
When to Conduct an When to Conduct an InvestigationInvestigation
ASAPASAP
Less physical evidence removed or altered More details remembered Haven’t had time to be biased by others
ACCIDENT QUESTIONS GUIDEACCIDENT QUESTIONS GUIDE
A CONDITION AN ACTIONWHY DID IT EXIST?
WHY WASN’T IT CORRECTED?
WHY WAS IT BEING DONE?
WHY WAS IT NECESSARY?
WHAT CAUSED IT TO EXIST? WHAT WAS ITS PURPOSE?
WHAT DETAILS NEED ELIMINATION?
WHERE WAS IT?
WHERE WAS ITS SOURCE?
WHERE SHOULD IT BE DONE?
WHERE ELSE IS IT BEING DONE?
WHEN DID IT OCCUR?
WHEN DO SIMILAR CONDITIONS OCCUR?
WHEN SHOULD IT BE DONE?
WHO WAS RESPONSIBLE?
WHO CAN GIVE ME ANSWERS?
WHO CAN GIVE ME ANSWERS?
WHO CAN SHOW ME WHAT WAS DONE?
HOW SHOULD IT BE CORRECTED?
HOW CAN IT BE AVOIDED?
HOW IS THE BEST WAY TO DO IT?
HOW CAN IT BE IMPROVED?
Can Accidents be Prevented?Can Accidents be Prevented?
Effective Management and Supervision Commitment to accident prevention Effective policies and procedures Effective reporting Employee training Job hazard analyses & inspections Safety culture
QUESTIONS & ANSWERSQUESTIONS & ANSWERS