Accident InvestigationYou Did What…Again?

Presented by:John Dietrich, Atkinson, Andelson, Loya, Rudd & RomoLaFaye Platter, Hemet USDLucy Rebuck, Hemet USDSuzanne Trowbridge, Keenan & Associates

Why Investigate?

• Prevent future incidents (leading to accidents). • Identify and eliminate hazards. • Expose deficiencies in process and/or equipment.• Reduce injury and worker compensation costs.• Maintain employee morale.• Meet DOSH rule requirement that you investigate

serious accidents.

“You can’t manage risk and change culture from behind a desk”

John Dietrich

“Common sense is not so common”

Lucy Rebuck

Investigate All Incidents and Accidents

Conduct and document an investigation that answers:

• Who was present? • What activities were occurring?• What happened?• Where and what time?• Why did it happen?

How Do You Investigate??

How To Investigate – Main Steps• Develop a plan• Assemble an investigation

kit• Investigate all incidents

and accidents immediately

• Collect facts• Interview witnesses• Write a report

Tips for Developing An Accident Investigation Plan

• Develop your action plan ahead of time.• Your plan might include:• Who to notify in the workplace?• How to notify outside agencies?• Who will conduct the internal

investigation?

Tips for Developing a Plan (continued)

• What level of training is needed?• Who receives report?• Who decides what corrections will be taken and

when?• Who writes report and performs follow up?

What Should Be in The “Investigation Kit”• Camera • Tape recorder• Gloves• Tape measure • Large envelopes• High visibility tape • Scissors• Personal protective equipment• First aid kit Report Forms

Root Cause Analysis

• Direct Cause – Unplanned release of energy or hazardous materials

• Indirect Cause – Unsafe acts and/or unsafe conditions

• Root Cause – Policies and decisions, personal factors, environmental factors

The Five Whys

Basic Question - Keeping asking “What caused or allowed this condition/practice to occur?”

The “five whys” is one of the simplest of the root cause analysis methods.

5 Whys In ActionSuzy had an unwitnessed trip and fall accident:

1)Why? She wasn’t looking where she was going2)Why? She was carrying a box3) Why? She was wearing inappropriate shoes4) Why? There was water on the ground5) Why?

Begin Investigation Immediately

• It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

Fact Finding• Witnesses and physical evidence• Employees/other witnesses• Position of tools and equipment• Equipment operation logs, charts, records• Equipment identification numbers• Take notes on environmental conditions, air quality • Take samples• Note housekeeping and general working environment• Note floor or working surface condition• Take many pictures• Draw the scene

Interview Witnesses

• Interview promptly after the incident• Choose a private place to talk• Keep conversations informal• Talk to witnesses as equals• Ask open ended questions• Listen. Don’t blame, just get facts• Ask some questions you know the answers to

Write The Report• Who• What• Where • When• Why – Root Cause• Prevention & Action Steps• Follow through

Case Study #1• Handout to be provided

Case Study #1 - Findings• Morale a result of poor supervision &

management

Case Study #2

• Eye Injury• Investigation results: wasn’t following safety

protocol; training provided on correct chemical handling

• Action steps:– Disciplined employee for failing to follow safety

protocols

Case Study #3

• Bus Driver Crashes Bus While Texting• Investigation:– Employee trained not to text– Employee observed texting on run in the am– Letter of reprimand at end of am shift for texting– Accident in pm while texting

Conclusion

• Root Cause Analysis

• Close Loop On Accident Investigation Findings

• Hold Everyone Accountable for Safety